168 ~ MACE Manual Second Edition MILLON™ ADOLESCENT CLINICAL INVENTORY by Theodore Millon, PhD, DSc, with Carrie Millon, PhD, Roger Davis, PhD, and Seth Grossman, PsyD‘MAC (Millon Adolescent Clinical Inventory) Manual (Second Edition) Copyright © 1993, 2006 DICANDRIBN, Inc. All rights reserved. Published by NCS Pearson, Inc. “BAL,” “Beck Anxiety Inventory,” “BDI,” “Beck Depression Inventory,” “BHS,” and “Beck Hopelessness Scale” are registered trademarks of The Psychological Comporation. “EDI” and “Eating Disorder Inventory” are trade~ marks of PAR, Inc, “M-PACT,” “MACI," “MAPI,” “MCMI,” “MCMLIL” and “Millon” are trademarks of DI- CANDRIBN, Inc. “DSM-IN-R” is a trademark and “DSM-IV” and “DSM-IV-TR” are registered trademarks of the American Psychiatric Association. WARNING: No part of this manual, or the inventory, answer and recording forms, noms, and scoring keys associated with it may be reproduced in any form of printing or by any other means, electronic or mechanical, including, but not limited to, photocopying, audiovisual recording and transmission, and portrayal or duplica- tion in any information storage and retrieval system, without permission in writing from NCS Pearson, Inc., PO Box 1416, Minneapolis, MN 55440 800-627-7271 www:pearsonassessiients.com Printed in the United States of America, ABCDAcknowledgments ‘The following institutions, clinics, and pri- vate practitioners were kind enough to pro- vide facilities and personnel for aspects of our research on the MACI test. Their contri- butions are gratefully acknowledged. Fox Valley Hospital, Green Bay, WI Appalachian Psychiatric Services, Beckley, WV Idaho Youth Ranch, Rupert, ID Charter Hospital of Northwest Indiana, Hobart, IN New Horizons Youth Ministries, Marion, IN Mill Creek Hospital, Visalia, CA Prairie View Mental Health Clinic, Newton, KS Philadelphia Psychiatric Center, Philadelphia, PA Park Center, Inc., Fort Wayne, IN Brown County Mental Health Center, Green Bay, WI Northwood Health Systems, Inc., Wheeling, WV South Central Counseling, Kearney, NE Child and Youth Services, Regina, Saskatchewan (Canada) Loma Linda Psychiatric Medical Group, Loma Linda, CA Welbom Clinic, Evansville, IN Lakeland Regional High School, Wanaque, NI Dr. Michael Rupley, Mishawaka, IN Medical and Counseling Associates, Richmond, VA Southern Oregon Adolescent Study & ‘Treatment Center, Grants Pass, OR Behavior Management Systems, Rapid City, SD Hampstead Hospital, Hampstead, NH Northwest Iowa Mental Health Center, Spencer, IA Children’s Medical Center, Tulsa, OK Baptist Medical Center Behavioral Medicine, Columbia, SC Family Learning Center, South Bend, IN Dr. George Middleton, Lake Charles, LA iit‘MAC | Manual Second Edition Mid-Michigan Regional Medical Center, Midland, MI Wichita Guidance Center, Wichita, KS Center for Child & Family Services, Marshalltown, [A Zumbro Valley Mental Health Center, Rochester, MN Forest Hospital, Des Plaines, IL. Willis Knighton Medical Center, Shreveport, LA Dr. William R. Merz, Sr, & Associates, Sacramento, CA Dr. John R. Haney, Decatur, AL LaSalle Clinic, Appleton, WI Ohilson Psychological Services, Anchorage, AK . Edmond Youth Council, Inc., Edmond, OK Green Hill School, Chehalis, WA Dr. Allan G. Hedberg, Fresno, CA Dr. Michael Dimitroff, Hammond, IN East Lansing Center for the Family, East Lansing, MI Dr. Donald W. Bonner, Duncan, OK Greenleaf Hospital, Jonesboro, AR Pine View Center Mercy Memorial Hospital, Monroe, MI Brighton Hospital, Brighton, MI Crossroads, Chattanooga, TN VisionQuest, Tucson, AZ. Tidewater Psychiatric Institute, Virginia Beach, VA. Dr. Tony R. Young, West Monroe, LA Clinical Associates of Tidewater, Virginia Beach, VA Alternative Rehabilitation Communities, Harrisburg, PA Erie County Medical Center, Department of Psychiatry, Buffalo, NY North Shore Child and Family Guidance Center, Rosalyn Heights, NY John Metcalf Junior High School, Burnsville, MN Bumsville High School, Burnsville, MN Hosterman Junior High School, New Hope, MN University High School, Honolulu, HI Dr. William J. Kleinpeter & Associates, Amarillo, TX. Pearson Assessments would also like to rec- ognize the following people for their contri- butions to the development and publication of the MACI test: Scott Allison, Kevin Anderson, Patricia An- derson, Suzanne Anderson, Tiffany Bakken, Christine Carlson, John Ficken, Terri Foley, Kathi Gialluca, John Kamp, Kelly Mayer, Ward Moberg, Kelly Morris Metzler, Steve Prestwood, Merry A. Rendahl, Dave Roble, Ron Rowan, Sue Steinkamp, Jeff Sugerman, Robin Thomsen, Sandy Whelan, and Lisa Yang.Table of Contents CHAPTER 1 Overview Distinguishing Features . History of the MACI Test. Uses + Limitations. . . Use of Information .. User Qualifications ......... CHAPTER 2 Guiding Theoretical System. Personality Patterns ......... Scale 1; Introversive . . Scale 2A; Inhibited Scale 2B: Doleful. . Scale 3: Submissive . Scale 4: Dramatizing . Scale 5: Egotistic Scale 6A: Unruly ... Scale 6B: Forceful Scale 7: Conforming ... Scale 8A: Oppositional . Scale 8B: Self-Demeaning .. Scale 9: Borderline Tendency. Expressed Concerns Scale A: Identity Diffusion ............. Scale B: Self-Devaluation Scale C; Body Disapproval Scale D: Sexual Discomfort. .. Scale E: Peer Insecurity .. Scale F: Social Insensitivity . . Scale G: Family Discord Scale H: Childhood Abuse .‘MAC | Manual Second Edition Clinical Syndromes ......... Scale AA: Eating Dysfunctions... Scale BB: Substance-Abuse Proneness.. Scale CC: Delinquent Predisposition... Scale DD: Impulsive Propensity Scale EE: Anxious Feelings Scale FF: Depressive Affect . Scale GG: Suicidal Tendency .. Structural-Functional Domains for the MACI Personality Patterns Behavioral Level.......... Phenomenological Level Intrapsychic Level . Biophysical Level... CHAPTER 3 Test Development............ Normative Samples. ... Clinician Judgments Scale Development... Base Rate Development... ; Specifying Target Prevalence Rates. Defining BR Anchor Points . Defining BR Scores for Scales 9 Through GG. Defining BR Scores for Scales 1 Through 8B... Defining BR Scores for Scales X, Y, and Z.... Grossman Facet Scales. CHAPTER 4 Psychometric Characteristics Relationship of MACI Scales to MAPI-C Scales Effect of Base Rate Transformations. ... Scale Intercorretations . . Reliability... eee eeseee Internal Consistency . Test Retest ..... Facet Scales Validity ee Correlations Between MACI Scores and Clinician Judgments aan Correlations With Scales From Collateral Instruments.......... CHAPTER 5 Administration and Scoring Administration......... Selecting Respondents. Preparation and Setting. . Directions and Explanations... Checking Answer Sheets........... vi 24 +24 24 eee 8 27 27 - 32 35 35 - 36 - 36 +37 37 yal, 38Table of Contents Scoring... eeeeceeeees Computer Scoring and Reports, Interpretive Report. Profile Report on) -. 50 or) . 81 Personality Code . 51 Unscorable Tests . 52 Invalid Tests. - 52 Hand Scoring ,.. bee Base Rate Transformations Base Rate Adjustments CHAPTER 6 Interpretation . Evaluating Questionable Inventories. .. Scale Descriptions. .... Personality Patterns Expressed Concerns. . 53 - 53 53 Clinical Syndromes .. 59 Clinical Profile Interpretations. a Rationale for Interpreting Profile Configurations . 60 Sectional Profile Analysis . Profile Integration. Case Histories . .. 5 » Case 1: Harold P. .. Case 2: Bruce D. Case 3: Peggy S. oe ...ecs References... eee cece ee eee ee eeeeeeeee eee sere 73 Appendixes A. Item Content...........000. ++ 75 B. Scale Composition and Item Weighting... 81 C. Base Rate Transformation Tables... . 89 C-1. 13- to 15-Year-Old Males. . 90 C-2. 16- to 19-Year-Old Males. 94 C-3. 13-to 15-Year-Old Females. . 98 C-4, 16- to 19-Year-Old Females. . . 102 D. Grossman Facet Scale Scoring.................. 107 E. Grossman Facet Scale Base Rate Transformation Tables sees ee ees +. 109 E.1 13-to 15-Year-Old Males. - 10 E.2 16- to 19-Year-Old Males. . . mw E.3 13- to 15-Year-Old Females ... . 12 E.4 16- to 19-Year-Old Females ......... 113 viiMACT | Manual Second Edition m Correlations Among MACI Scale Scores (Samples B and C)... . i. Correlations Between MACI Scale Scores and Scores on Collateral Instruments (Sample B) .....sseeceevees Gl. Correlations Between MACI Scale ‘Scores and POSIT Subscale Scores G-2. Correlations Between MACI Scale Scores and EDI-2 Subscale Scores . . 2 G-3. Correlations Between MACI Scale Scores and BDI, BHS, and BAI Scores H. Sample Interpretive Report. ........... Bonoeecceccoaa |. Noteworthy Responses. . J. Sample Profile Report K. Score Adjustments. .. Tables 1.1 Scale Names and Number of Items per Scale............ cc. cee eeee es 2.1 Expression of MACI Personality Patterns Across Structural- Functional Domains 3.1 Demographic Characteristics of the Development and Cross-Validation Samples . 3.2 Demographic Characteristics of Norm Groups in the Development Sample (A) 3.3 Instructions and Information Provided to Clinicians for Making Judgments Concerning Each Adolescent . 7 3.4 Frequency Table of BR Scores for Scales x y, and Z (Total Normative Sample) 4.1 Correlations Between MACI Base Rates and MAPI-C Base Rates and Between MACI Base Rates and MACI Raw Scores 4. iS for MACI Base Rate Scores ..... see 4,3 Scale Lengths and Internal Consistency Reliability ‘Estimates for ‘the Grossman Facet Scales... 2.00... 00... ceeceseeeeeeeeeeeeereeees seeees 4.4 Correlations Between MACI Base Rates and Clinician Judgments i in Two Cross-Validation Samples . wee . 6.1 Descriptions of the Grossman Facet Scales . . Figures 6.1 MACI Interpretive Model 6.2 Profile for Case 1: Harold P, 6.3 Profile for Case 2: Bruce D. ... 6.4 Profile for Case 3: Peggy S. ...... viii Scale Lengths and Internal Consistency and Test-Retest Reliability Estimates 5 123 124 126 128 129 441 43 151 26 29 eal poe - 38 42CHAPTER | 1 Overview ‘The Millon™ Adolescent Clinical Inven- tory (MACI™) is a 160-item self-report inventory designed specifically for assess- ing adolescent personality characteristics and clinical syndromes. Table 1.1 lists the 31 MACI scales and the number of items on each scale. The MACT test and its forerun- ners were developed in consultation with psychiatrists, psychologists, and other men- tal health professionals who work with ado- Jescents; as a result, they reflect the issues that are most relevant to understanding the behavior and concerns of adolescents. The MACI test was developed for use in clini- cal, residential, and correctional settings. It is useful in the evaluation of troubled ado- lescents, and it may be used for developing diagnoses and treatment plans and.as an ¢ come measure... ‘The MACL test has been an evolving assess- ment tool (see “History of the MACI Test” later in this chapter), with each successive version refined and strengthened to incorpo- rate developments in theory, research, and professional nosology. The current release of the MACI test continues this tradition with the addition of the Grossman facet scales for the Personality Pattems scales. The new fac- et scales help pinpoint the specific personal- ity processes (e.g., self-image, interpersonal HaSS That underlie overall elevations on ‘the Peisonality Patterns scales, thereby aid- ing in their interpretation. This second edi- tion of the MACT manual has been updated to incorporate the addition of the facet scales and to make the manual more current. Distinguishing Features The following paragraphs briefly delineate features that distinguish the MACI test from other personality and clinical instruments. Further chapters will more fully address these varied aspects of the inventory. 1. The MACI test was constructed with an adolescent population in mind. The test items are presented in language that teenagers use, and they deal with matters that are relevant to teenagers’ concems and experiences. This contrasts with other commonly used clinical inventories that were designed for use primarily with adult populations. 2. Even the most elegantly constructed psychometric tool is not likely to be widely accepted if its content, length, and linguistic style are unwieldy. A ma- jor goal in the development of the MACI test was to construct an inventory that had enough items to accurately assess a variety of personality traits, psychologi- cal concems, and clinical syndromes yet ‘was short enough to encourage its use in a variety of clinical settings. The MACI test’s reading level and vocabulary were set to allow for ready comprehension by the vast majority of adolescents. The fi-MACI | Manual Second Edition Table 1.1 Scale Names and Number of Items per Scale Scale Name Number of Items Personality Patterns 1 Introversive 2A Inhibited 2B Doleful #0 3*» 3 Submissive 4 Dramatizing 5 Egotistic 6A Unruly Ryan B Forceful qvewt 7 Conforming 8 8a Oppositional teegad Wtked BF. a) 8B Self-Demeaning sdada he 9 Borderline Tendency Expressed Concerns : A Identity Diffusion 32 B Self-Devaluation 38 c Body Disapproval — a¢s! «0 "7 D Sexual Discomfort 37 EB Peer Insecurity 19 F Social Insensitivity 39 G Family Discord 28 H Childhood Abuse 4 Clinical syndromes AA Eating Dysfunetions 20 BB Substance-Abuse Proneness 35 cc Delinquent Predisposition 34 oo) Impulsive Propensity m EE Anxious Feelings 2 FF Depressive Affect 3 GG Suicidal Tendeney 25 Modifying Indices x Disclosure = a Y Desirability 7 Zz Debasement 16 w Reliability A 4 This score is calculated from sale seores, not tems.oe fy Leten}ientn. geared to ySixth: \ 6, ing level, can be completed by most adolescents in 20-25 minutes. ‘The brevity and clarity Of thé instrument facilitates quick administration with a minimum of client resistance. . Basing a diagnostic instrument on a comprehensive theoretical system sig- nificantly increases its clinical utility. The MACI test’s personality and clinical scales are grounded in a comprehen- sive theory (Millon, 1969, 1981, 1986a, 1986b, 1990, 1992; Millon & Davis, 1996). . Clinical psychologists, counselors, and psychiatrists who work with adolescents were involved throughout all phases of development of the MACI test and the predecessor instruments from which it evolved. During the early stages of test development, counselors, psychiatrists, and psychologists were interviewed to identify issues that are relevant to troubled adolescents, As a result, the Expressed Concems scales target sig- nificant developmental problems of adolescence, and the Personality Patterns and Clinical Syndromes scales reflect significant areas of pathologic feelings, thoughts, and behavior that require pro- fessional attention, . The capacity to differentiate various problem areas is central to the effective- ness of the inventory. Hence, all MACI item selections were made by comparing a targeted criterion group (c.g., based on Personality Patterns and Clinical Syndromes) with a general but troubled adolescent population. The use of a clini- cal reference group should substantially increase discrimination efficiency and enhance the accuracy of the assessment. CHAPTER | 1 Overview Most psychological instruments employ standard score transformations (such as T scores) that assume a similar dis- tribution of individuals for each trait or syndrome continuum. However, both theory and research fail to support this assumption. Consequently, the MACI test employs actuarial base rate or preva- ence data to establish scale cutting lines. This approach ensures that the frequency of various MACI high-point scale and profile configurations will correspond closely to actual pattern and disorder frequencies within a clinical adolescent population. . Item selection and scale development progressed through three validation stag- es: (a) theoretical-substantive, (b) inter- nal-structural, and (c) external-criterion. This approach created an instrament that meets the standards of developers who are committed to diverse construc- tion and validation methods (Hase & Goldberg, 1967). Because these steps proceeded sequentially, each item had to pass satisfactorily through all three stages of development to be retained in the inventory. In this way, the MACT test ‘meets the basic criteria of each construc- tion method, rather than being limited to only one validation procedure. . A computerized narrative report is avail- able for the MACI test. The narrative report integrates information about the individual's personality traits, psycho- logical concerns, and clinical syndromes. This individualized narrative is presented in the style of a clinical case report. Scale elevations and profile configura- tions are interpreted on the basis of theory and clinical research.RS MAC | Manual Second Edition History of the MACI Test ‘The original Millon Adolescent Inventory was developed in 1974 and served as the forerunner to the MAPI™ test (Millon Ado- escent Personality Inventory), which was first published and distributed by Pearson Assessments (then NCS) in 1982. The Mil- Jon Adolescent Inventory and the MAPI test were identical in item content but differed in the norms they employed and the purposes for which they were intended. The MAPI test was subsequently divided into two forms. The MAPI-G(uidance) test was de- signed for school settings to help counselors better understand adolescent personalities and identify those students who might ben- efit from further psychological workups. The MAPI-C(linical) test was designed to help mental health workers assess teenagers who exhibited emotional or behavioral disorders and who were in a diagnostic or treatment setting at the time of testing. A mixed clini- cal and nonclinical population provided.the norms for the MAPI-C test, a decision that led to a loss of precision when seeking a relevant reference group for individuals en- gaged in clinical appraisals. ‘The decision to develop a purely clinical ref- erence group with appropriate comparison norms served as the impetus for constructing the MACI test. Beyond the need for relevant norms, it was evident that the MAPI-C test, useful as it was for diagnostic assessment, ‘was not sufficiently broad-based to encom- pass the full range of clinical populations. Numerous experienced clinicians who had used the MAPI-C test over a 10-year period recommended ways to enhance the instru- ment by adding scales for syndromes such as depression, anxiety, substance abuse, and delinquency. Although minor adjustments to the MAPI-C test were introduced regularly during this period, there was clearly a need to overhaul and ultimately replace it with a tool that would strengthen its psychometric features, broaden its clinical scope, make it more consonant with developments in its guiding theory, and fortify its coordination with the descriptive characteristics ini the most recent DSM (Diagnostic and Statisti- cal Manual of Mental Disorders) classifica- tions. Within the restrictions on validity set by the limitations of self-report, the narrow frontiers of psychometric technology, and the slender range of consensually shared diagnostic knowledge, all possible steps were taken to maximize the MACI test’s concordance with its generative theory and with the official DSM classification system. Pragmatic and philosophical compromises were made, however, where valued objec~ tives could not be simultaneously achieved (eg, instrument brevity versus item inde- pendence, representative national patient norms versus local base rate specificity, and theoretical criterion considerations versus empirical data). Cross-validation and cross- generalization studies have been executed with the goal of evaluating and improving items, scales, scoring procedures, algo- rithms, and interpretive texts. These studies will continue to provide an empirical foun- dation for further upgrading of each of these components. More specifically, and with the preceding goals in mind, the following changes and ad- ditions characterize the differences between the MAPI-C and MACI tests. 1, Four new Personality Patterns scales were introduced in the MACI test be- yond the eight that constituted the per- sonality segment of the MAPI-C test. Moreover, the item content of the eight original personality scales was sub- stantially changed to reflect theoretical developments, empirical research, and DSM criterion modifications. Several scale names were also changed to reflecttheir clinical characteristics more pre- cisely. The four new MACT personality scales are Doleful (reflecting the depres- sive personality introduced in the DSM- 1V@; American Psychiatric Association, 1994), Forceful (representing the DSM- II-R™ sadistic personality; American Psychiatric Association, 1987), Self-De- meaning (similar to the DSM-IILR self- defeating personality), and Borderline ‘Tendency (sharing the DSM-I [Ameri- can Psychiatric Association, 1980] des- ignation and bringing a gauge of severity into personality evaluations with the MACT test). .. The Expressed Concerns scales were renamed to more clearly reflect the problems they assess (¢.g., Self-Concept became Identity Diffusion). One scale, Academic Confidence, was deleted on empirical grounds and because of its limited clinical relevance. A new scale, Childhood Abuse, was added in response to the increasing significance of child- hood abuse in clinical evaluation. . Procedures were added for correcting various distortion effects (e.g., random responding, faking good, faking bad). ‘Three “modifier” scales (Disclosure, Desirability, and Debasement), which are similar to those incorporated inio the MCMI™ test series, were developed for this purpose. . Another important difference lies in the revision of several scales designed to identify and quantify various Axis- type clinical syndromes and the ad- dition of new scales. The MAPI Social Conformity and Impulse Control scales were revised and renamed Delinquent Predisposition and Impulsive Propensity, respectively. New Clinical Syndromes scales developed for the MACI test were CHAPTER | 1. Overview Bating Dysfunctions, Substance-Abuse Proneness, Anxious Feelings, Depressive Affect, and Suicidal Tendency. 5. To provide for the additional scales de- scribed above, and as a result of cross- validation and cross-generalization stud- ies, only 49 items from the MAPI test were retained and 111 new items were introduced, resulting in the 160-item MAC test. Where feasible and appropri- ate; these new items were fashioned to reflect DSM-IIL-R and DSM-IV additions and diagnostic criterion changes. 6. An item-weighting system was incorpo- rated into MACT scoring to reflect differ- ences between scale items in their con- sonance with the instrument’s guiding theory and the extent of their supporting validation data. 7. The narrative text in the MACI automat- ed interpretive reports is substantially ‘more detailed than the text for the MAPI reports, including extensive integra- tion of Personality Pattern and Clinical Syndrome configurations, The MACI re- ports also reflect general advances in the instrument's underlying theory (e.g., see Millon, 1990) and progress in its coordi- nated sets of diagnostic criteria (Millon, 1986a, 19866). Uses ‘The MACI test was designed to be used by mental health professionals as an aid to identifying, predicting, and understanding a wide range of psychological problems that are characteristic of adolescents. It may be routinely used upon entrance into mental health settings as an instrument for adoles- cent clinical assessment. The empirically validated scales that make up the MACI test‘MAC | Manual Second Edition likely to exhibit acting-out behavior, anxious feclings, and guicidal tendencies. Assessing possible strengths as well as weaknesses, the MACT test can help the clinician maximize potential by building on the full scope of personality attributes rather than focusing on problem areas alone. Further, the brevity and ease of MACI administration, scoring, and interpretation facilitates its use in a wide variety of clinical settings, Limitations ‘The MACT test was developed to assess ado- lescents in diverse mental health settings. Norns were established employing clinical samples of(3- to 1Dyear-olds. Use of the MACI test witir nonclinical populations or with any other age group is inappropriate and might lead to erroneous information, Professionals working with 9- to 12-year-old clients are urged to consider teen Adolescent Clinical Inventory (S{-PACI™), also published by Pearson Assessments, Use of Information MACT results can be obtained either as a simple profile of scores or as an automated interpretive report with scores and computer generated interpretive text. By themselves, score profiles provide limited information and require extensive knowledge of the rel- evant clinical literature for interpretation. ‘The more comprehensive and detailed inter- pretive report is considered a professional- to-professional consultation. Its function is to serve as one component in the evaluation of the adolescent, and it should be viewed by the clinician as a series of probabilistic rather than definitive judgments. It is appro- priate to use this information in developing a therapeutic program, but sharing the report with clients or their families is discouraged. Careful rephrasing of text interpretations may be undertaken with appropriate clients, using sound clinical judgment to assure a constructive outcome. Finally, the user must comply with all legal and professional guidelines regarding recordkeeping, confi- dentiality, and release of information. User Qualifications All test materials and reports offered by Pearson Assessments have been assigned one of four qualification levels (A, B, M, or ) according to the credentials required to purchase products at that level. The MACI test is a Level A product. Level A purchasers must provide credentials indicating: + licensure to practice psychology inde- pendently or + a graduate degree in psychology or a closely related field AND either gradu- ate courses in tests and measurement or completion of a Pearson Assess- mentsapproved workshop or other approved course or + proof that they have been granted the right to administer tests at that level in their jurisdiction.CHAPTER | 2 Guiding Theoretical System Its extremely useful to have a consistent theoretical system on which to base a coher ent classification of personality and a frame- work for developing a parallel set of inven- tory scales. The guiding text for the MACI Personality Pattems scales, Modern Psycho- pathology (Millon, 1969), describes such a theoretical system. Despite its wide range of clinical applicability, the theory is based on derivations from a simple combination of a few variables or constructs. Personality Patterns ‘The 12 MACI Personality Patterns scales reflect the way in which personality traits and features combine to form a pattern. The theoretical basis for these Personality Pat- tems has been presented in numerous books over the past thrée decades (e.g., Millon, 1969, 1981, 1986a, 1986b, 1990, 1991; Mil- on & Davis, 1996). The theory proposes that both normal and abnormal personality styles can be derived by combining three polarities: pleasure-pain, active-passive, and self-other. For example, the dependent personality style (measured by the MACI Submissive scale) may be seen in a person who is adaptively passive and oriented to the needs of others. By contrast, an antisocial personality (measured by the MACI Unruly scale) is considered to be adaptively active and self-oriented. Readers interested in an in-depth treatment of the theoretical model are advised to consult one or more of the aforementioned books. A description of the theoretical basis for each of the MACI Per- sonality Patterns scales is presented in the following sections. Scale 1: Introversive Introversive adolescents lack the capacity-to -experience life-as either painful or pleasur- able. Their personalities are similar to the DSM-IV schizoitpersonality in that they tend to be apathetic, listless, distant, and asocial. Emotions and needs for affection are minimal, and the individual functions as a passive obsérver detached from the rewards, affections, and demands of human relation- ships. Because of their diminished capacity to experience both pain and pleasu 10- versive teenagers do not seem to be interested in personal enjoyment or social satisfaction, nor do they evidence much discomfort when faced with personal difficulties or social dis- cord. Deficits such as these across both ends of the pleasure-pain polarity underlie what is Aspects of the developmental background and clinical features of the Introversive personality may provide the reader with a sense of how abstract concepts such as pain and pleasure can be conceived as relevant etiologic attributes, Introversive adolescents neither strive for rewards nor seek to avoid punishment. Deficiencies such as these may arise from several sources, Some may lack the constitutional makeup required for seck- ing, sensi rriminating pleasurable‘MACI | Manual Second! Edition or painful events. Others may have been _deprived.of the stimulation necessary for the maturation of motivational or emotional ca- pacities. Still others may have been exposed ‘(o irrational and confusing family communi- “cation or to contradictory patterns of leam- ing, both of which may result in cognitive perplexities or motivational apathy. Whatever the complex of causes may have been, Intro- versive adolescents experience little or no pleasure or pain to motivate their behavior. Scale 2A: Inhibited MI Furr Inhibited, the second clinically meaning- ful combination based on problems in the pleasure-pain polarity, deseribes adolescents with a diminished ability to experience pleasure but an unusual anticipation of and sensitivity to psychic pain. These adoles- cents expect life to be distressing, with few rewards and much anguish, The imbalance of anticipated psychic pain and diminished psychic pleasure lies at the heart ofthis per- sonality type. The Introversive, Inhibited, and Doleful types share a minimal sense of joy and contentment, but only the Inhibited type is also disposed to feel apprehension and angst. The theory classifies the Introver- sive and Inhibited types as detached; how- ever, whereas the Introversive type is pas- sive-detached, the Inhibited type is active- detached. Unable to experience pleasure, these detached types (as well as the Doleful) tend to drift into isolating circumstances and self-alienated behavior. Scale 2B: Doleful ‘There are commonalities among the first three MACT Personality Patterns, notably glumness, pessimism, lack of joy, the in- ability to experience pleasure, and seeming motoric retardation. For the Introversive pat- tem, there is an incapacity for both joy and sadness. For the Inhibited pattern, there is a hyperalertness to anticipated pain, with a consequent inattention to joy. For the Dole- ful, there has been a significant loss, a sense of giving up, and a loss of hope that joy can be retrieved, None of these personality types experience pleasure, but for different reasons: for the Introversive a deficiency; for the Inhibited an orientation to pain; and for the Doleful despair about the future, a disheartened, woebegone outlook, and an irreparable and irretrievable state of affairs in which what might have been is no longer possible, Similar to the DSM-IV depressive person- " ality type, the Doleful personality type experiences pain as permanent, with plea- sure no longer considered even possible. ‘What experiences or chemistry accounts for such persistent and characteristic sadness? Clearly, there are biological dispositions to take into account. The evidence favoring a constitutional predisposition is strong, much of it favoring genetic factors. The thresholds involved in permitting pleasure or sensitiz~ ing one to sadness vary appreciably. Some individuals are inclined to pessimism and a disheartened outlook. Similarly, experience can condition a hopeless orientation. A sig- nificant loss, a disconsolate family, a barren environment, and hopeless prospects can all shape the Doleful character style. Scale 3: Submissive Following the theory's polarity model, we next consider the clinical consequences that ‘occur among adolescents who are mark- edly unbalanced by virtue of turning almost exclusively toward others or toward them- selves as a means of experiencing pleasure and avoiding pain. Such individuals differ from the Introversive, Inhibited, and Dole- ful types. For example, these three types do not experience pleasure from self or others. ‘Teenagers whose difficulties are traceable to the problem of choosing one or the other pole of the-self-other dimension do experi- ence pain and pleasure; their problem arisesinstead from being tied almost exclusively cither to others or to themselves as the source of these experiences. The distinction between these two contrasting strategies underlies the dependent and independent personality orientations, The theory specifies two dependent personality patterns, which correspond to the MACI Submissive and Histrionic scales, Adolescents who exhibit the Submissive pat- tem—as with its DSM-IV counterpart, the dependent personality—have leamed that feeling good, secure, and confident (feelings associated with pleasure or the avoidance of pain) comes almost exclusively from their relationships with others. Behaviorally, these adolescents display a strong need for external support and attention. If they are deprived of affection and nurturance, they experience marked discomfort, sadness, and anxiety. Any number of early experiences may set the stage for this dependency. A teenager with a Submissive personality may have been overprotected and as a conse- quence may have failed to acquire autonomy and initiative, Experiencing low self-es- teem and failure with peers may lead these individuals to forgo attempts at self-asser- tion and self- gratification. They leam early that rewarding experiences are not readily achieved alone but are secured by leaning n others. They learn not only to tum to oth- ers for nurturance and security, but to wait passively for others to take the initiative in providing safety and sustenance. Clini- cally, most are characterized by a search for relationships in which others will reliably furnish affection, protection, and leadership. ‘They passively accept whatever circum- stances bring them. Scale 4: Dramatizing Also turning to others as the primary coping strategy is a personality style that represents an active dependency stance. Adolescents CHAPTER | 2. Guiding Theoretical System with this style achieve their goal of maxi- mizing protection and nurturance by busily engaging in a series of manipulative, seduc- tive, gregarious, and attention-getting ma- neuvers. Its this active dependency imbal- ance that characterizes the behavior of the MAC Dramatizing personality as well as its DSML-IV parallel, the histrionic personality disorder. Although tuming to others to no less an ex- tent than the Submissive passive-dependents, Dramatizing types appear on the surface to be quite dissimilar from their passive coun- terparts. This difference in overt style is the result of the active-dependent’s facile and enterprising manipulation of events, which ‘maximizes attention and favors from oth- ers and avoids social disapproval or neglect. of confidence, ance. However, beneath this guise lies a fear of genuine autonomy and a need for repeat- ed signs of acceptance and approval. Tribute and affection must be constantly replenished and are sought from every interpersonal source in most social contexts. Scale 5: Egotistic Adolescents with an independent personality type also exhibit an imbalance in their cop- ing strategies. In this case, however, there is a primary reliance on self rather than others. ‘They have learned that maximum pleasure and minimum pain are achieved by turning exclusively to themselves. The tendency to focus on self follows two major lines of personality development. The first, the Ego- listic pattern, involves the acquisition of a self-image of superior worth, learned largely in response to admiring and doting parents. Rewarding oneself is highly gratifying if one values oneself or has a real or inflated sense‘MAC | Manual Second Edition of self-worth, Displaying confidence, narcis- sistic arrogance, and an exploitive egocen- tricity in social contexts, these individuals exhibit what is called the passive-indepen- dent style in the theory because they feel that they have all that is important—them- selves. Egotistic adolescents are noted for their sense of entitlement from others and for ex- periencing pleasure simply by passively at- tending to themselves. Early experience has taught them to overvalue themselves. This confidence and superiority, perhaps founded on false premises, may be unsustainable by real or mature achievements. Nevertheless, they blithely assume that others will recog- nize their specialness. As with their DSM parallel, the narcissistic personality, they maintain an air of arrogant self-assurance and exploit others to their own advantage without much thought or even conscious in- tent. Although the tributes of others are wel- come and encouraged, the Egotistic’s air of snobbish and pretentious superiority requires little confirmation through genuine accom- plishment or social approval. Their sublime confidence that things will work out well provides them with little incentive to engage in the reciprocal give-and-take of social life. Scale 6A: Unruly Unruly adolescents, those whom the theory characterizes as exhibiting the active-in- dependent orientation, exhibit the outlook, temperament, and socially unacceptable behavior of the DSM antisocial personal- ity disorder. They act to counter anticipated deceit and derogation at the hands of others. They do this by actively adopting a hostile and duplicitous manner and by engaging in illegal behavior through which they seek ret- ribution or the exploitation of others. Skepti- cal regarding others’ motives, these adoles- cents desire autonomy and seek revenge for what they feel are past injustices. Many act 10 impulsively and irresponsibly and feel justi- fied in doing so because they judge others to be unreliable and disloyal. Insensitivity and ruthlessness with others are the primary means they have learned to use to head off what they see as abuse or victimization. In contrast to the Egotistic personality, the Unruly pattem of self-orientation develops as a form of protection. These adolescents turn to themselves, first to avoid the dep- redation they anticipate, and second to compensate by furnishing self-generated rewards. Learning that they cannot depend on others, they counterbalance this loss by trusting only themselves and by actively seeking retribution for what they see as past humiliation, Turning to themselves and ac- tively seeking to gain strength, power, and revenge, they act irresponsibly, exploiting others and usurping their possessions. Their security is never fully assured, even when they have aggrandized themselves beyond their diminished origins. Scale 6B: Forceful There are some adolescents for whom the usual properties associated with pain and pleasure are conflicted or reversed. These teenagers not only seek or create objectively painful events but experience some of them as pleasurable. The variant of pain-pleasure reversal represented by the Forceful person- ality style (similar to the DSM sadistic per- sonality disorder) is characterized by view- ing pain (stress, fear, cruelty) rather than pleasure as the preferred mode of relating to others. In contrast to the Self-Demeaning type, discussed later, the Forceful adolescent assumes an active role in controlling, domi- nating, and intimidating others. Acts that humiliate, demean, and abuse others are ex- perienced as pleasurable. The Self-Demean- ing and Forceful Personality Patterns are grouped under the theory's discordant label to reflect, on the one hand, the dissonantstructure of their pain-pleasure systems and, on the other, the conflicted character of their interpersonal relations. The Self-Demeaning type, often on the receiving end of fractious relationships, is referred to as passive-dis- cordant, whereas the more expressive Force- ful type is considered active-discordant. The Forceful personality style includes ado- lescents who may not necessarily be judged unruly or antisocial but whose actions sig- nify that they find pleasure in behavior that humiliates others and violates their rights and feelings. Depending on social class and other moderating factors, these teens may display the clinical features of what is known in the literature as the sadistic char- acter. They are generally hostile and perva- sively combative, and they appear indifferent to or even pleased by the destructive conse- quences of their intimidating, contentious, and abusive behavior. Scale 7; Conforming This conflicted Personality Pattem is similar to the DSM obsessive-compulsive personal- ity disorder. Conforming adolescents display a distinct other-directedness and a consis- tency in social propriety and interpersonal respect. Their histories usually indicate that they have been subjected to constraint and discipline, but only when they transgressed parental strictures and expectations. Beneath the compliant and other-oriented veneer are intense desires to rebel and to assert their ‘own self-oriented feelings and impulses. ‘They are trapped in this ambivalence. ‘To avoid intimidation and punishment, they have learned to deny the validity of their own wishes and emotions and to adopt the values and precepts set forth by others. The disparity they sense between their own urges and the behavior they must display to avoid condemnation often leads to physical ten- sion and rigid psychological controls. CHAPTER | 2. Guiding Theoretical System Etiologically, Conforming adolescents are likely to have been coerced into accepting standards imposed on them by others. As noted, their prudent, controlled, and perfec- tionistic ways derive from a conflict between Tepressed anger toward others and a fear of shame, guilt, and social disapproval. They resolve this ambivalence not only by sup- pressing resentment but also by overcon- forming and by placing heavy demands on themselves. Their disciplined self-restraint serves to control intense though hidden op- positional and self-centered feelings, result- ing in their characteristic hesitation, doubt, passivity, and public compliance. Behind these adolescents’ front of propriety and re- straint lurk intense, angry feelings that may occasionally break through their controls. Scale 8A: Oppositional In the dependent (Submissive and Dramatiz~ ing) and independent (Egotistic and Unruly) orientations, adolescents demonstrate pa- thology through a coping strategy that is un- balanced in terms of its excessive orientation toward others (dependent) or toward them- selves (independent). An imbalance toward self or others is not the only maladaptive pattern along the theory’s self-other polarity. “Normal” individuals exhibit a comfortable intermediaté position between the polarities of self and others. Personality Patterns speci- fied by the theory as ambivalent also attend to both self and others, but experience an intense conflict between one and the other. Adolescents characterized by the ambiva- lent pattem called Oppositional (similar to the DSM-III passive-aggressive personality and the DSM-IV negativistic personality) vacillate between others and self, sometimes behaving obediently and sometimes react- ing defiantly. Feeling intensely, yet unable to resolve their ambivalence, they weave an erratic course between voicing their self- deprecation and guilt for failing to meet the expectations of others and expressing stub- ee‘MAC | Martual Secor Edition bom negativism and resistance over having submitted to the wishes of others. Adolescents whose conflicts between self and others are expressed overtly are called actively ambivalent, The Conforming per- sonality also struggles between following the rewards offered by others and those desired by the self. Whereas the passive Conforming types hide their ambivalence, actively ambivalent (i.e., Oppositional) personalities are conscious of the conflicts that intrude into their everyday lives. These adolescents involve themselves in endless wrangles and experience disappointment as they fluctuate between deference and obedience and defiance and aggressive nega~ tivism. Their behavior displays an erratic pattern of explosive anger or stubbornness intermingled with guilt and shame. Scale 8B: Self-Demeaning ‘The Self-Demeaning Personality Patter stems largely from a reversal of the pleasure- pain polarity. These adolescents interpret events and engage in relationships in a man- ner that is not only at variance with the func- tion of this deeply rooted polarity (survival) but is contrary to the associations these emo- tions usually acquire through leaning. To the Self-Demeaning adolescent, pain may have become preferable to pleasure, pas- sively accepted if not encouraged in intimate relationships. It is often intensified by pur- poseful self-denial and acceptance of blame and may be aggravated by acts that engender difficulties and by thoughts that exaggerate past misfortunes and anticipate future ones. Relating to others in an obsequious and self- sacrificing manner, these adolescents allow or even encourage others to exploit them (similar to the DSM masochistic personal- ity). Focusing on their very worst features, many assert that they deserve to be shamed and humbled. To compound their pain and anguish, these adolescents may actively and 12 repetitively recall their past misfortunes and transform otherwise fortunate circumstances into problematic ones. Typically acting in an unassuming and self-effacing way, they often intensify their deficits and place them- selves in an inferior or abject position. ‘The background of the Self-Demeaning Per- sonality Pattern has been a topic of consider- able speculation for decades, most promi- nently in the psychoanalytic literature on masochism. The role of biological anomalies is a domain of speculation that cannot be totally dismissed, but it does strain credulity. More credible perhaps are hypotheses of a developmental or social learning nature. For example, by virtue of circumstantial associa- tion, elements that normally evoke pain and pleasure could very well become transposed or interconnected. Thus, among adolescents who become self-demeaning, the pain of physical brutality or the anguish of verbal abuse may have been followed repeatedly by love and intimacy, leading to the learned assumption that provocation is a necessary precursor to ultimate acceptance and tender- ness, In a more complicated sequence, ab- solution of guilt may have been successfully achieved by repeated self-abasement, acts that generalize over time into a broad pattern of self-denial and servility that “undoes” negative consequences. Scale 9: Borderline Tendency Three severely dysfunctional personality styles contained in the DSM—schizotypal, borderline, and paranoid—are also rep- resented in the theory. They differ from the preceding patterns by several criteria, notably deficits in social competence and frequent (but treatable) psychotic episodes. Moreover, they almost invariably coexist with and are more intense variants of the Personality Pattems discussed previously. For example, Borderline personalities tend to exhibit features that are similar to butmore problematic than those found in the Oppositional and Self-Demeaning types. Less integrated in terms of their personal- ity organization and less effective at coping than their milder counterparts, they are es- pecially vulnerable to decompensation when faced with the everyday strains of life. The MACL test measures only one of the three severe patterns, Borderline Tendency. The other two are relatively infrequent among adolescents. ‘The Borderline Tendency scale is set apart from the other MACT Personality Patterns scales in the MACI score profile to reflect its greater severity. Severity was gauged in part by estimating the probability that a particu- Jar personality orientation would fit well into one or another of the sociocultural niches in contemporary society. In other words, we souight fo assess the likelihood that the per- sonality pattern would be able to maintain its structural coherence and function in a socially acceptable and personally rewarding manner. All three of the severe Axis Il disor- ders are adaptively problematic, difficult to relate to socially, and often isolated, hostile, or confused, Hence, they are not likely to elicit the interpersonal support that could bolster their flagging defenses and orient them to a more effective and satisfying life- sole Moreover, there is a clear breakdown in these disorders. ‘The Borderline Tendency pattern corre- sponds to the theory's emotionally dysfunc ‘tween pleasure and pain, active and passive, and self and other. Adolescents with this per- sonality pattern seem unable to take a con- sistent, neutral, or balanced position among these polar extremes, tending to fluctuate from one end to the other. They experience {intense endogenous moods with recurring CHAPTER | 2 Guiding Theoretical Sysiem Periods of dejection and apathy, often inter- “Aiong the features that distinguish ‘from their less severe personality co- variants is the instability and lability of their moods. Additionally, many express and may act on recurring self-mutilating and cupied with securing affection. difficulty maintaining a consistent sense of identity. Interpersonally, most display a cognitive-affective ambivalence, evident in simultaneous feelings of rage, love, and guilt toward others. These features represent a ow level of structural cohesion in their psy- chic organization. For many there is a split within their interpersonal and intrapsychic orientations. They are unable to build inner structural coherence and maintain consisten- cy in their personal relationships or in their defensive operations. There are fundamental intrapsychic dissensions, core splits between taking an independent or a dependent stand, between acting impulsively or withdrawing into passive disengagement, between fol- Jowing the wishes of others or doing the op- posite of what others wish. They repeatedly undo or reverse the actions they previously took, thereby further embedding the reality of being internally divided. It is both feasible and productive to employ the key dimensions of the theoretical model to make the clinical features of the MACI Personality Patterns more explicit, from the actively pain-sensitive Inhibited pattern to the passively self-centered Egotistic pattern, from the actively other-oriented Dramatiz~ ing pattem to the self-other conflicted Op- positional type. The adaptive styles derived from the theory do not generate distinctions between personality structures such as those that characterize the severe disorders. How- ever, they do enable the identification of al- ternate styles in which these more pathologi- cal structures are expressed. This explains 13MAC |, Manual Second Edition the presence of frequent mixtures such as Dramatizing borderlines, Forceful border- lines, and Oppositional borderlines. Expressed Concerns ‘The eight scales in the Expressed Concerns group focus on feelings and attitudes about issues that tend to concem troubled adoles- cents. The intensity of experience is reflect- ed in the score elevation for each scale, Note that these scales represent perceptions rather than objectively observable or behavioral criteria. Scale A: Identity Diffusion Adolescence is preeminently a period of ex- amination: of self, of others, and of beliefs. Before adolescents can comfortably leave the security of childhood dependence, they must formulate some idea of who they are, where they are going, and how they might get there. It is their task to build a bridge that will allow them to cross the chasm from unreflecting childhood attachments to estab- lishment of an independent self with a clear understanding of who they are. This transition from unexamined childhood to adult identity, at times chaotic and trou- bling, is the focus of the Identity Diffusion scale. Factors such as rewarding parent-child relationships and competent same-sex role models must exist to facilitate the effective development of identity (Block & Turula, 1963; Heilbrun & Fromme, 1965).Con- versely, circumstances can arise that lead to increased difficulty and an inability on the Part of the adolescent to develop a mature identity. Beginning with body changes and an expanded world of choices, the adoles- cent must adapt and select goals. Adoles- cents who lack suitable role models or who have experienced confusing or angry mes- sages from parents and peers will find this 14 shift overwhelming and frightening. If the prospects are frightening enough, they can prevent movement, causing adolescents to remain unsure of who they are or where they might go and to choose to hold onto their familiar confusion and discomfort rather than brave the unknown. Such a stance only produces further problems. The resolution of the identity issue is cen- tral to the adolescent’s capacity to establish independence, to become a member of a peer group, and to develop a sexual iden- tity, Without a clear sense of values and a personal identity, healthy development is unlikely. Despite the difficulties, however, most adolescents do construct a foundation for their identity in early and middle ado- lescence. This foundation is strengthened as they acquire patterns of social affiliation and vocational purpose. A certain degree of questioning and self- doubt is not only inevitable but necessary for developmental progression. Adolescents who simply espouse ideals formulated by their parents may have acquired a role but may later face serious difficulty in accept- ing this externally imposed sense of self. A necessary process may have merely been delayed. Development of an identity does not demand the rejection of parental values but rather the examination and integration of those values along with the values of the larger world that the adolescent is entering. Scale B: Self-Devaluation Atno time prior to adolescence is the developing individual subjected to such critical self-scrutiny. Children tend to see themselves in terms of what should be, with the ideal often closely approximating their Parents. Early adolescence, however, ush- ers in a painful period of comparison of self against ideals that seem far beyond what the adolescent has considered previously. Itis the disparity between these two, and the struggles to resolve them, that are the focus of the Self-Devaluation scale. This struggle is closely tied to the adolescent's efforts to develop his or her own identity. What we see is the adolescent formulating a tentative sense of who he or she is. Itis in this area, perhaps more than any other, that the adoles- cent's strengths will often intensify confficts, yet ultimately help him or her to grow and resolve difficulties. ‘The ideal self we create tends to be fairly consistent across individuals; we all want to be brave and smart and attractive. However, individuals vary tremendously in how they perceive themselves in relation to this ideal. ‘Two major factors affect this perception: the presence of real deficits that make the attainment of the ideal impossible, and the intensity with which the person critically evaluates him- or herself. Adolescents have formulated ideals consisting of wealth and power but will feel that they cannot achieve these goals if they have limited ability or are denied opportunities because they are mem- bers of a disadvantaged minority (Dreger & Miller, 1968), On the other hand, such high ideals may seem very distant to more advan- taged or more insightful adolescents who can analyze and recognize the differences between themselves and the expectations and standards they have set for themselves. ‘The introspection of these adolescents will serve them well over time and perhaps en- hance a greater congruence between self and reality (Katz & Zigler, 1967). Itis significant that adolescents with low self-esteem are less popular with their peer ‘groups yet show the highest need for social approval. Seeking to gain this recognition and acceptance, they make willing pawns for other group members, often behaving in ways they would not otherwise, consider ex- cept for their desperate need t8 be accepted CHAPTER | 2 Guiding Theoretical System by others (Dittes, 1959; Walster, 1965; Zim- bardo. & Formica, 1963). In spite of such pitfalls, the developmental process moves on, The process continues into late adolescence, usually with increas- ing comfort and self-acceptance. Dissatis- faction with self becomes a highly personal marker of unhappiness and not merely an index common to most adolescents, With maturity, adolescents Ieamn not to blame oth- ers for their own difficulties. Scale C: Body Disapproval Children accept growth and change as just another aspect of everyday existence. When changes occur, they feel gradual and are integrated with only limited awareness. By contrast, the changes that occur during early to middle adolescence are of a very different nature. Growth is rapid, affecting sexuality and creating significant physical changes in shape, form, and attractiveness. Wishes and ‘dreams regarding appearance now stand in sharp relief against an emerging physical self. How the adolescent views him- or her- self rests, in part, on facets of objective body build, but this physique is judged in the con- text of a myriad of experiences and societal norms (Ausubel, 1954). This judgment pro- cess is highly complex, a product of parental attitudes, personal fears, peer reactions, and one’s own critical self-awareness. ‘The age at which pubertal changes occur is significant, particularly for boys (Frazier & Lisonbee, 1950). Early development, evident in facial hair and an increasingly muscular body, is seen as very positive, of- ten leading to a sense of self-satisfaction, increased interest in athletics, and general confidence, Delays in these changes often Iead adolescent males to be less assertive and less inclined to assume leadership roles, pattems that may persist well after maturity (Washburn, 1962). Whereas the ideal bodily‘MACI | Manual Second Edition form in males is consonant with the typical features of maturation, female adolescents are often caught in a painful bind as they develop physically, Some of the much- awaited changes (e.g., breast development) are linked to other characteristics of less appeal, including wider and heavier thighs and hips. The blessings of growth are mixed, and the female adolescent is often harshly critical of what she sees as obvious imper- fections compared with the cultural feminine ideal of being shapely, slender-hipped, and long-legged. A painful sense of diminished attractiveness may complicate other aspects of adolescent adaptation, especially her rela- tionships with male peers. ‘This process of self-examination, judgment, and integration of physical appearance and body image is greatly affected by the reac- tions of others. A prime factor is the attitude that family members take in minimizing or ameliotating problems. Negative family at- titudes can create and intensify facial and body-image dissatisfaction, even among adolescents who are experiencing typical growth changes (Schonfeld, 1966). ‘The majority of physical changes have taken place by late adolescence. For good or bad, the individual has assumed a relatively final bodily and facial configuration. Unfortu- nately for many adolescents, dissatisfaction with their appearance often remains equally immutable. Scale D: Sexual Discomfort From the first moment an infant is dressed in pink or blue, preparation for the role as an adult—a gender-defined adult—begins. Despite progress toward equal treatment and equal opportunities for boys and girls, the process of inculcating the young with tradi- tional male and female roles continues. As the child continues to mature, awareness of parental attitudes toward sexuality and its 16 expression grows. Children often leam not to touch their genitals and, if caught, sense some shame or embarrassment. Early explor- ation often moves from innocent curiosity to furtive and guilt-ridden examination. Even when parents are tolerant, other adults often convey the attitude that sex is problematic. Early adolescence often brings anticipation of new opportunities and challenges. The teenager faces the task of reconciling beliefs Jeamed earlier with new and strong sexual stirrings. This process entails developing an image of being a person with sexual im- pulses that are capable of expression and the achievement of pleasure. The ability to inte- grate these sexual impulses into the frame- work of one’s self-image will have a distinct bearing on how the teenager will feel about and form sexual relationships. The effective transition to sexual aware- ness and comfort is not a product merely of maturation and parental acceptance. Rather it occurs as a product of a complex interac- tion between timely biological maturation, acceptance of change, and a developing sense of self that allows this new aspect to be integrated. Another consideration is the adolescent's willingness to move beyond the somewhat safe and dependent role of child- hood into one that leads to the assumption of adult responsibilities. The adolescent juggles all aspects—the bio- logical stirrings, the social insecurities, and the self-conscious yearning—to create the idealized adult role. After a tremulous start, most adolescents do achieve a meaning- ful sexual expression, one combining both friendship and intimacy. The ease and rate of this transition is gauged by the Sexual Dis- comfort scale, reflecting problematic paren- tal attitudes, cultural beliefs, and the impact of peers, all of which contribute to sexuality and its acceptance. Immature attitudes anda troublesome sense of guilt or shame are tapped to aid the clinician in helping teen- agers with these problems: Scale E: Peer Insecurity As in childhood, age-mate groups allow adolescents to practice relating at a stage of development common to all. Of course, peer standards exist and there is pressure to con- form to them, but adolescents appear to use the peer group primarily to balance their de- pendency needs with their aspirations for in- dependence. Adolescents see the peer group as a source of support while they try to dis- tance themselves from parental values and domination. Although peer group affiliation does not encompass all aspects of a teen- ager’s life, it does make up and influence a significant portion of social behavior. Most younger adolescents seek a large number of friends and are rather unselective in their peer group choices. However, as self-con- fidence and self-awareness grow, teenagers begin to make choices within the peer group to develop closer friendships and to support the values they have begun to espouse. ‘Most adolescents go through an early period of intense involvement with their peer group, followed by a gradual distancing as they are accepted by others and feel free to move to the more intimate friendships of later adoles- cence, However, adolescents with poor self- esteem are caught in a particularly desperate bind, Expecting rejection, they often remain timid and passive observers on the sidelines of life. Evaluating them for group member- ship, their peers assess their personality and behavior and often grant them only limited access. As a consequence, they fail to re- ceive the attention and recognition that en- courage their more successful peers to gain self-confidence and autonomy. They remain locked in this early stage of peer affiliation, pathetically needing group approval and therefore accepting even the low status ac- CHAPTER | 2 Guiding Theoretical System corded, which they feel is necessary to main- tain some semblance of group membership. Those with the greatest assets—lively, cheerful, good-natured, humorous ado- lescents—receive the growth-enhancing rewards of peer approval. Those with defi- cits—ill-at-ease, timid, nervous individu- als—are trapped by diminishing self-esteem, seeking something to cling to. These unfor- tunate individuals are easy marks for those who grant them recognition in exchange for absolute allegiance, and this submission can Iead to commitments far removed from their intrinsic values and true potential. The Peer Insecurity scale measures the adolescent's degree of success in finding a comfortable, rewarding position in his or her peer group. Scale F: Social insensitivity ‘The family inculeates children very early with beliefs regarding appropriate behavior, ‘This is achieved through a combination of admonition, praise, and implicit modeling. In the absence of these early efforts, and sometimes in spite of them, some children will fail to accept these beliefs as their own. ‘The degree to which such children deviate from these tenets will affect their views and interpersonal behavior. What feelings does a person who deviates in this manner harbor? How is interpersonal insensitivity expressed, and what behavior can be expected from such a person? Further, what impact will this individual have on others, and what will their subsequent reactions evoke? The Social Insensitivity scale addresses these issues. ‘The most salient behavioral characteristic of this type of individual is a generalized indifference to the feelings and reactions of others. This differs from overt hostility; rather, it shows a casual indifference to the presence of discomfort and pain in others. Often uncaring and seemingly unmoved by needs for reciprocal social relationships, this ”7‘MACI | Mantial Seooid Edition type of person may choose isolation, apa- thy, or insensitivity. Such an individual may eschew ordinary restraints and actively es- pouse views that are contrary to the rights of others. Most frequent is either a diminished interpersonal life or a willingness to ride roughshod over those who are in the way. For these individuals, it is simply easier not to care than to modify their behavior. Although the intensity of these feelings ranges along a continuum, the distribution is by no means a normal one. Rather, the vast majority of adolescents will, like their par- ents, at least pay lip service if not actually adhere to beliefs that include respect for the rights of others. Some individuals, however, rather than adopt this position assume a far harsher stance, one with serious ramifica- tions for family, school, and society. Their tough, insulated, and negative view creates a situation in which the adolescent remains virtually unmoved by inducements to maxi- mize social conformity. How often have psy- chologists interviewed adolescents who have run afoul of regulations, only to be astound- ed by their absolute indifference to the pain of others as they insolently slouch in their chair, waiting for the lecture to end, at which time they will dismiss the whole incident as irrelevant? The frustration experienced by clinicians stems from an inability to touch these adolescents, to awaken those feelings that are necessary to stimulate change. The issue here is not a developmental one in the sense that all adolescents must work through this phase to achieve a greater maturity. Rather, the issue gains its significance by virtue of society's need to influence these individuals to develop an awareness of how their behavior is destructive to others and also creates consequences for themselves. Scale G: Family Discord ‘The image that often comes to mind when the word adolescent is mentioned is that of an angry teenager storming out the front door after yet another disagreement with his or her parents. Society’s habit of equating dissent and disobedience with the adolescent period is widespread, but the true nature of this behavior and its meaning are less clear. Is the adolescent really a rebel, and if so, what is the nature of this rebellion? Farther, what role does the family play in precipitating, exacerbating, or ameliorating the conflict? Finally, how are these problems resolved within the home and outside it? The teenager’s relationship to his or her family, along with perceptions of what it should be, is the focus of the Family Discord scale. This scale assesses the adolescent's feelings and perceptions, not what is objectively real. In many ways, home and family serve as an external arena in which an intemal struggle between independence and dependence can safely take place. Both inclinations—au- tonomy and the privileges of maturity on the one hand, safety and nurturance on the other—are powerfully positive. Both have drawbacks, responsibility for the former, and inadequacy of self for the latter. This devel- ‘opmental task is complicated further because maturity requires both independence and the capacity to rely on and relate to others, including parents. Adolescent oppositional behavior is a curious phenomenon when examined, even if one ignores its specific content. Younger adolescents seek to stand up for themselves as individuals capable of making their own decisions. They perceive their parents as opponents in this battle. It is not a battle over the content of one belief or andther but rather the right to establish their ‘own expectations. Adolescent growth does not occur in a vacuum. Parents vary in their ability to deal with these changes. Further, adolescence oftén arrives during a developmentally dif- ficult period for parents. They may be sens-Pap ing a “loss of horizons,” an awareness that life is unlikely to improve significantly. Mortality becomes more real as the parents of the adolescent assume the role of caretak- ers for their own parents, witnessing their deterioration and eventual death. These ad- 4itional stresses often lead parents to feel beleaguered, accused unjusily of shortcom- ings by their children at a time when they need nurturance and reassurance themselves. Consequently, they may seem unyielding or unsympathetic to their child’s pleas to be heard, or they may be irritated by the adoles- cent's difficult behavior, The resolution of these adolescent conflicts will depend on the intensity of inner strug- gles and parental reactions toward efforts at autonomy. This process is present in all adolescents; it often reflects not so much dif- ferences in beliefs and values (Offer, 1969) but rather a need to separate and achieve independence from what is experienced as incompatible with further maturity. Scale H: Childhood Abuse Victimization is obviously not exclusively a problem of childhood and adolescence, but children are a special class of dependent and vulnerable individuals. The emergence of family social structures sanctioned the sub- ordination of children to their elders, which left them at risk for neglect and abuse and specified their legal status as the property of their parents. The codification of family law protected children from the vicissitudes and dangers of the Jarger culture but left them entirely vulnerable within the family. Subject to almost absolute control in their homes, they were vulnerable to potentially unlimited physical, mental, and sexual abuse. In the late nineteenth century, both Pierre Janet and Sigmund Freud recognized that the origins of adult hysteria, especially CHAPTER | 2. Guiding Theoretical System among women, could often be traced to the after-effects of being sexually abused as chil- dren, Janet focused his attention on a variety of traumatic events, employing the concept of dissociation to explain how the memory of these events becomes disconnected from the mainstream of normally associated ideas. Freud was especially interested in the con- nection between sexual trauma and later pa- thology. Although Freud later repudiated his earlier thesis of child seduction as a reality, substituting childhood “fantasies” as the pri- mary etiologic agent in what he termed the Oedipus complex, he continued to empha- size the role of psychic trauma in his later theories. It is well established that childhood trauma and abuse are major elements in the devel- ‘opment of later psychopathology. Retro- spective studies of psychiatric inpatients suggest that perhaps one-third to one-half have histories of physical or sexual abuse or oth. Females appear to be more likely than males to be victims, especially of sexual abuse. Abused males are likely to react by f-defeating per- Sonalities. Abuse during childhood appears io increase the risk that its victims will abuse their own children, According to recent stud- ies, approximately one-third of those who were physically abused, sexually abused, or severely neglected will mistreat their own children. This intergenerational transmission of abuse appears to be magnified among parents who are socially isolated and fail to be acculturated into more healthy forms of childrearing. Emotional abuse is a generic term encom- passing several variants of parental mistreat- ment (e.g., rej rizing, ignoring,MACI | Manual Second Edition isolating, corrupting). Sexual abuse, a spe- ‘cific and especially problematic form of both physical and emotional abuse, appears to be prevalent in the history of about 20% of col- lege-age females and 7 or 8% of college-age males. Sexual contact between siblings is the most common form of incest, although incestuous activity between daughters and their fathers or stepfathers is more likely to be reported. Incest and other sexual abuse survivors exhibit a wide variety of adoles- cent and adult psychopathology, including tion, role con- self-« esteem, symptoms, and aggressive and borderline personality features. ‘The Childhood Abuse scale was designed to uncover abuse in the adolescent’s back- ground. It should be noted that this scale measures only the adolescent’s perception and recollection of these events; it does not necessarily affirm the reality of such experi- ences. Clinical Syndromes ‘The seven scales that make up the Clinical Syndromes group assess disorders that man- ifest themselves in relatively specific forms; that is, the symptomatology will cluster into clear-cut and well-defined clinical syn- dromes such as anxiety or depression. These syndromes are usually the initial focus of treatment, standing out as relatively dramatic and notable behavior, thought, and/or feeling patterns that call attention to the person as one who requires professional help. ‘The Clinical Syndromes are best seen as ex- tensions or distortions of an adolescent's ba- sic personality. These syndromes tend to be relatively distinct and transient states, wax- ing and waning over time depending on the impact of stressful situations. Typically they caricature of accentuate the teenager’s basic personality style. Regardless of how distinc- tive these syndromes appear to be, they take on meaning and should be appraised with reference to the adolescent's personality. Ad- ditionally, itis clear that certain of the syn- dromes arise most frequently in conjunction with particular personality styles. For ex- ample, Depressive Affect (Scale FF) occurs most frequently among Inhibited, Doleful, and Self-Demeaning adolescents. Substance- ‘Abuse Proneness (Scale BB) is found com- monly among Unruly and Forceful teens. However, this does not preclude the possibil- ity of less common combinations. Because of the interrelationships between the MACI Clinical Syndromes and Per- sonality Patterns, constructing a model in which these relationships can be specified is crucial, Although Clinical Syndromes and Personality Patterns are assessed indepen- dently, each Clinical Syndrome should also be coordinated with the specific Personal- ity Pattern with which itis related. Most of the Clinical Syndromes described in this section are of the reactive kind that are of substantially briefer duration than personal- ity disorders. They usually represent states in which an active pathological process is @learly manifested. Many of these symptoms are precipitated by external events. As noted, most appear in somewhat striking or dramat- ic form, often accentuating or intensifying the more prosaic features of the premorbid or basic personality style. During periods of active pathology, it is not uncommon for several symptoms to be present at any one time and to change over time in their relative prominence. Scale AA: Eating Dysfunctions As with the other Clinical Syndromes, the underlying impetus for anorexic and bulimic behavior varies considerably, as does thedegree of danger it poses, the severity of as- sociated psychopathology, and the extent to which itis reactive to environmental stress- ors, Depending on the interaction of these factors in the life of the adolescent, eating disorders can suddenly materialize from nowhere, disappear for a period, and then re-emerge with or without a manifest pre- cipitant. It is only recently that wide-ranging and longitudinal data have begun to accumu late on the prevalence of these dysfunctions and their waxing and waning course. Anorexia nervosa was identified in the lat- ter part of the nineteenth century as a major psychological dysfunction involving self- starvation by young girls. Recognition of bulimia as a disorder is much more recent. A specific translation of the term would be “ravenous appetite”; it has come to mean binge eating, followed by purging behavior, typically vomiting. Like anorexia, bulimia is associated with excessive body preoccupa- tion and concern with weight, and both dis- orders may be present simultaneously. The Eating Dysfunctions scale assesses the like- lihood that the adolescent is suffering from an eating disorder. Scale BB: Substance-Abuse Proneness Although adolescent preferences for various specific alcoholic beverages and illicit drugs (including tobacco) may rise and fall rather rapidly, long-term trends do not appear to support an inexorable increase in overall teen use of alcohol and drugs, despite the impression of many adults. What we have seen in recent years is the continuation of substance abuse among certain troubled ado- lescents, rather than a mass cultural trend. The issue to be discussed is who uses drugs and alcohol to excess, why do they do it, what age groups and course do they follow, which substances do they employ, for how long, and for what purposes. CHAPTER | 2 Guiding Theoretical System Clearly, substance abuse is a major problem for society and for mental health services. This problem is of major importance among the poor anid disadvantaged who seek sub- stances to ameliorate their sense of hopeless- ness and their rejection of societal norms. It is in the province of mental health services that psychological assessment can play a central role, This is especially the case when such tools can not only identify abuse pres- ence or proneness but can also point to the personologic context within which abuse arises, Through the Substance-Abuse Prone- ness scale, the MACI seeks to provide an un- derstanding of why substance abuse occurs and what purpose it serves for an adolescent with a specific personality pattern. Scale CC: Delinquent Predisposition ‘Numerous conflicts and internal struggles can cause adolescents to have problems; an equally large number can lead adolescents to become problems, Adolescents who have problems usually demonstrate their distress by exhibiting troubled behavior among fam- ily, friends, and teachers. Adolescents who are problems gain attention by the distress they inflict on others and through a disregard for ordinary societal constraints. What is the nature of this inability or unwillingness to comply with societal regulations? How does this habit of disregard develop, and what paths are best followed in search of remedia- tion? ‘Underlying “delinquent” behavior is not a single trait but rather a constellation of fee!- ings, cognitions (or their lack), and behavior that culminate in acts against others. There is no modal delinquent individual. Instead, there appear to be at least two distinct groups of adolescents, largely divided along socioeconomic lines. Although members of these two groups possess very different sets of feelings and personality traits, their few shared behaviors cause them to be labeled 2! * MACT| Manual Second Edition together. One group consists of individuals with very low academic self-esteem, which may be based on real difficulties with school endeavors; among these teéns there is a gen- eral turing away from achievement. In the other group, family life is often described as chaotic or hostile, with parents often acting out in an antisocial way. A central character- istic of these adolescents is impulsivity with- out concern for eventual consequences. Even when they understand consequences, these adolescents may choose to ignore them, showing indifference to the possibility of punishment and often remaining impassive when it does occur, The situation is further complicated by the fact that the peer culture may be supportive of illegal behavior. The larger society is punishing the very behav- ior for which these adolescents are being rewarded within their more intimate social group. Scale DD: Impulsive Propensity Maturity is often held up as a standard to which all should aspire. Yet even assuming that everyone, adolescents and adults alike, _ had a common interpretation of maturity, the path from childhood to autonomous and responsible behavior in adulthood would be fraught with difficulties. As adolescents be- gin to move toward autonomy, they feel both the need and the right to speak out and be- have in a manner that is consonant with their new belief system. Although such behavior is not unusual in adolescence, it is often viewed as an unwelcome change, grudgingly tolerated by parents and teachers. What can adolescents safely express, and what is merely self-indulgent or hostile rhetoric? The excesses in manner by which growing adolescents demonstrate this assertiveness are the focus of the Impulsive Propensity scale. Even when they are subject to strong emo- tions, growing adolescents make repeated 22 decisions to control their impulses. However, both their capacity to maintain these controls and their willingness to do so is reduced dur ing this period as they increasingly believe that they have the right, even the obligation, to express their views. Adding fuel to the fire is the impact of biological changes that often increase moodiness and self-assertion. Society has dealt with this in some measure by establishing a “psychosocial” moratorium (Erikson, 1968), a period in which ordinary rules for evaluating conduct are relaxed. ‘There is an expectation that adolescents will have some troubling feelings and that these in tum will be demonstrated in behavior that is ordinarily considered inappropriate, The issue that remains is what is acceptable (that is, how great a degree of deviance from the norm is permissible, and how should it sub- sequently be managed). Impulsive behavior is distributed along continuum, and society and individual families establish clear markers along this continuum concerning what is or is not ac- ceptable. First, there are behaviors that regu- larly earn approval and even accolades. Next lie those behaviors which, while not com- mendable, are seen as a part of growing up, designed to test limits and develop a sense of self; these are permissible and within the range of the psychosocial moratorium, Next are those behaviors that exceed the limits of tolerance in the family or at school. These acts quickly exasperate adults and lead to increased friction and an increasing spiral of acting-out behavior. For males, this type of behavior usually involves excessive aggres- sion, whereas females are noted more fre- quently for acting out sexually. The most ex- treme form of behavior is not only upsetting within the family and at school, but is also outside the bounds of general societal regu- lation; this type of behavior was discussed in the Delinquent Predisposition section.Scale EE: Anxious Feelings Anxiety is a universal emotion, However, it is considered a serious psychological disor- der if it occurs frequently, persists for long periods, cannot be explained by realistic stressors, and upsets the individual’s ability to relate socially or to function adequately. Anxious adolescents often report feeling either vaguely apprehensive or specifically phobic. They are typically tense, indecisive, and restless, and they tend to complain of a variety of physical discomforts, such as tightness, excessive perspiration, ill-defined muscular aches, and nausea. A review of responses to the specific items on the Anx- ious Feelings scale will aid in determining whether the adolescent is primarily phobic and, more specifically, if the phobia is of either a “simple” or a “social” variety. How- ever, most anxious adolescents exhibit a generalized state of tension, manifested by an inability to relax, fidgety movements, and a readiness to react and be easily startled. Somatic discomfort—for example, clammy hands or an upset stomach—is also char- acteristic. Also notable are worrisomeness and an apprehensive sense that problems are imminent, a hyperalertness to one’s environ- ment, edginess, and generalized touchiness. Itis not uncommon for anxiety to be ex- pressed through somatic channels, persistent petiods of fatigue and weakness, and a pre- occupation with ill health and a variety of severe but largely nonspecific pains in differ- ent and unrelated regions of the body. Some anxious adolescents have multiple somatic complaints, often presented in a dramatic, vague, or exaggerated way. Others have a history that may best be considered hypo- chondriacal; they interpret minor physical discomfort or sensations as signifying a seri- ‘ous ailment. If disease is actually present, it tends to be overinterpreted, despite medical reassurance. Typically, somatic complaints are employed to gain attention. CHAPTER | 2 Guiding Thepretical System Scale FF: Depressive Affect ‘The majority of depressed adolescents re- main involved in everyday life but are preoc- cupied with feelings of discouragement or guilt, a lack of initiative, apathy, low self- esteem, futility, and self-deprecation. Dur- ing these periods of dejection, there may be tearfulness, suicidal ideation, a pessimistic outlook, social withdrawal, poor appetite or overeating, chronic fatigue, poor concentra- tion, loss of interest in pleasurable activities, and decreased effectiveness in performing ordinary and routine tasks. Unless the De- pressive Affect scale is notably elevated, there is litle likelihood that major depres- sive features exist. Close examination of responses to specific items should enable the clinician to discern the particular features of the individual's dysthymic mood (for ex- ample, low self-esteem or hopelessness). Depressed adolescents in inpatient units may be incapable of functioning in a normal environment, are severely depressed, and express a dread of the future, suicidal ide- ation, and a sense of hopeless resignation. Some exhibit marked motor retardation, whereas others display an agitated quality, incessantly pacing and bemoaning the sorry state of their lives. Somatic disturbances are often present during these periods—notably, decreased appetite, fatigue, weight loss or gain, insomnia, or early rising. Problems of concentration are common, as are feelings of worthlessness or guilt. Repetitive fearfulness and brooding are frequently in evidence. Depending on the adolescent's characteristic personality style, there may be a shy, intro- verted, and seclusive pattern characterized by sluggish immobility or an irritable, com- plaining, and whining tone. Scale GG: Suicidal Tendency Suicide-related behaviors may be conceived along a continuum. This continuum extends from thoughts about intentional self-injury 23“MAC | tamial Second Edition or death (suicidal ideation) to intentional self-injury (self-destructive behavior) to unsuccessful suicidal behavior (suicide at- tempts), to, finally, successful attempts (Suicide). Any elevation on the Suicidal Ten- dency scale should be taken seriously. Although adolescents facing psychosocial problems often think of suicide as a way out, few act on these thoughts in a serious man- ner, Nevertheless, epidemiologic data indi- cate that successful suicides increase sharply during adolescence. Self-inflicted harm is a more frequent cause of death among 15- to 19-year-olds than in any other age group. Many factors, often in concert, serve as the impetus for suicide. Although impulsive suicide attempts are infrequent, they do oc- cur in adolescents who have had persistent family difficulties or have experienced a troubling break-up of a significant relation- ship. Feelings of emotional isolation, a lack of supportive social networks, and a sense of peer alienation appear to be prime factors in the lives of adolescents who view suicide as their sole recourse. Structural-Functional Domains for the MAC! Personality Patterns The theory that underlies the MACI Per- sonality Patterns specifies eight domains through which each personality is expressed. Four of these domains—expressive behavior, interpersonal conduct, cognitive style/con- tent, and regulatory mechanisms—are called functional because they represent modes of regulatory action. The remaining four domains represent psychic substrates and action dispositions of a quasi-permanent nature and are therefore referred to as struc- tural. The structural domains are self-image, 24 object répresentations, morphologic organi- zation, and mood/temperament. Another way of parsing the eight domains is according to the data levels they represent: behavioral, phenomenological, intrapsychic, or biophysical. Note that these levels cor- respond to the four historic approaches to the study of psychopathology, and therefore to the four main schools of modern thought in terms of intervention. Following is a brief overview of the eight functional and struc- tural domains, grouped according to data level. More detail may be found in Millon (1990); Millon and Davis (1996); Millon, Millon, Meagher, Grossman, and Ramnath (2004); and Millon, Millon, Davis, and Grossman (2006). Behavioral Level Expressive Behavior. A functional domain, this construct relates to observable acts. An adolescent's overt behavior may reveal directly what he or she wishes to convey to others, or it may help the clinician deduce, via inference, information the teen reveals unwittingly. Interpersonal Conduct. This functional do- main represents the adolescent's style of re- Jating to others. It is one of the more reveal- ing domains in terms of the person’s social needs and habits and one of the more diverse domains in terms of expression (e.g., it may be captured in many different ways, such as how actions affect others or self, method of interaction, etc.). Phenomenological Level Cognitive Style/Content. Another functional, domain, this relates to the adolescent's tend- encies in the areas of focusing and allocating attention, gathering and filtering information, and making decisions about the relative im- portance of various thoughts. This includes both thought content and thought process.Self-Image. This structural domain relates to the adolescent's self-view or identity and the relative quality that self-concept holds. Itis especially significant in that it serves as a guidepost and lends continuity to chang- ing experience. It is important to consider the clarity, accuracy, and complexity of the individual’s self-image. Object Representations. Past experiences leave inner imprints, and this structural do- main represents this residue of memories, attitudes, and affects that may shape the adolescent's experience of the outer world, specifically other people, Despite its psycho- dynamic roots, this domain appears on the phenomenological level rather than the in- trapsychic because it serves as a perceptual filter for the external world, often within the boundaries of awareness, Intrapsychic Level Regulatory Mechanisms. These internal processes, akin to what have been classi- cally termed defense mechanisms, represent a functional domain that may usually be observed only through inference. These dy- namic regulatory mechanisms co-opt and transform both internal and external realities before those realities can enter conscious awareness in a robust, unaltered form. Morphologic Organization. This structural domain represents the overall architecture that serves as a framework for an individu- al’s psychic interior. When weakened, it may be described as lacking cohesion, exhibiting poor coordination of its components, or ill- CHAPTER | 2 Guiding Theoretical System equipped to mediate various psychic pres- sures, Biophysical Level Mood/Temperament, This final structural domain is reflective of the adolescent's characteristic affect and the intensity and frequency with which he or she expresses it, While some qualities within this domain (cg., affect) may be easy to decode, oth- ers (e.g., mood) may be more subtle and pervasive, interweaving consistently and/or repetitively with the teen’s relationships and experiences, Table 2.1 provides an overview of the ex- pression of each of the MACI Personality Patterns in each of the eight structural-func- tional domains. For example, the Introver- sive pattem is characterized by expressive behavior that is impassive, interpersonal conduct that is unengaged, an impoverished cognitive style, and so on. The Table 2.1 entries shown in*bold represent Personal- ity Pattem by domain combinations that are measured by the Grossman facet scales.’ As described in more detail in later chapters, there are three facet scales for each of the 12 MACT Personality Patterns, with each of the facets representing one of the eight struc- tural-functional domains. The facet scales information in Chapter 6 includes more complete descriptions of the personality by domain combinations that are shown in bold in Table 2.1. For more detail on the expres- sion of the MACI Personality Patterns across all domains, the reader should consult the sources mentioned above. 25i 3 2 3 2 AHISa 20 w-11-70SC a9 30 xipuadde a9 [09 UF uous ame Safes aoe; sSOOD Aq pOINswOU! am eK SUTEWOP 9A aN "LANA, add 0020519 SIU « jeieg 499 204 310N or es wosaidee | rgneduoouy ] — wyramsun, sepa, Topepeeg pounds oumpepioR “auapuan ‘uuapieg auondsca povenct woneeiieg | panpeiona | Sujuosopun ePua, wma ‘woueay serene | Bueowea eS ‘rar wetiona wwounoedic | Sopmee | pamumaoong wong Gea mn PAREN reuonseda| ‘wuerog | pecmsunedinaa Powesone | monmapmuey | pea Teneo poundpia | eaindweo Bumnoweg erry wore ea@s95 eawaiioa saseaay somndaaa Ps “ann paseseat snomoaaey red uedsay | samnndeay poaay Tenors ‘rounds angen, sassy oagsuedia noe ‘aso, ‘nemo ona pamtonia somres woe ‘Gina | Banpeg-uonaeny | onewmicr “Borneaea Sued 7 ast uy oN ‘10 vwavaduiooay | wopueder ania co paride aye ona, Sass swoon | yanienlec, 9 peuey ae 7 epesen venmueay Pea rayon WopIOAY earuat suewedy | panueegipan | womamosqauy | sale vweomdiuay | poysuavoday | paleduoug saisediay ‘anjsianonuy wouesoduey susiueyoan | suonewasaidey waq009 ranpuog soweyeg weed ‘w09w Asoveyn304 veafao afeuryas | eitis eapquteg | yeuosrodsowy | onpssaudng yeuosied tov ve e1geL SUIEWOg /BUOOUN-jeINJONAg ssoloy stiaNeg ANjeUOsiag [QYIN JO UOIssasdxy 28CHAPTER | 3 Test Development The process of revising the MAPI test to produce the MACI test began with the se- lection of 181 new items from a large item pool. These new items were written for two purposes: (a) to sample the domains represented by the new MACI Clinical ‘Syndromes and (b) to provide items for re- vising the MAPI Personality Patterns and Expressed Concems scales. Each item con- sisted of a statement describing a feeling or behavior. Adolescents were to indicate (by responding True or False) whether the state~ ments described their feelings and attitudes. These new items were added to the original 150 MAPT items, and the resulting 331-item form was called the MACI Research Form. Normative Samples Participation in the revision process was solicited from psychologists and other clini- cians who used the MAPI-C(linical) report for evaluating and treating adolescents. (See “History of the MACI Test” in Chapter 1 for a description of the MAPI-C.) The revision project involved more than 1,000 adoles- cents and their clinicians from 28 states and Canada. Data were collected between May 1991 and February 1992. Each adolescent participating in the project was administered the MACI Research Form and was also rated by his or her clinician on several relevant characteristics, The project consisted of two phases. In the first, the adolescents were randomly divided into two groups: (a) a large development sample (Sample A), which was used for the selection of the final MACT items and for de- fining the scales and the base rate transfor- mations, and (b) a cross-validation sample (Sample B), which was used for evaluating MAC scale scores. Data were collected separately from a third sample (Sample C) in the second phase of the project (between June and October of 1992). These data were also used for cross-validation. Adolescents in the first phase of this proj- ect (Samples A and B) were administered two instruments in addition to the MACI Research Form. Data from these collateral instruments were used for scale construc- tion and validation and included the follow- ing: (a) the Eating Disorder Inventory™-2 (EDI™-2; Garner, 1991), (b) the Beck Anxiety Inventory® (BAI®; Beck & Steer, 1990), (c) the Beck Depression Inventory® (BDIG; Beck & Steer, 1987) and the Beck Hopelessness Scale® (BHS®; Beck & Steer, 1988), and (4) the Problem Oriented Screen- ing Instrument for Teenagers (POSIT; Na- tional Institute on Drug Abuse, 1991). Clinicians were instructed to administer to each client the collateral instrument that best fit the client’s initial diagnosis. (For example, adolescents who presented with depression‘MACI |‘Manual Second Edition or mood problems were administered the BDI and BHS.) In addition, a second colla- teral instrument was assigned to each parti- cipating research site to be administered to all adolescents assessed at that site. (When- ever the assigned test was the same as the test selected as best fitting the adolescent's presenting problem, the clinician was free to choose another test to administer.) Ado- escents in Sample C were administered the ‘MACT Research Form only; no collateral in- struments were administered to these subjects, A total of 1,017 adolescents and their clini- cians participated in the MACI development project (806 in the first phase and 211 in the second phase). In both phases, adolescents were retained in the research sample only if, they met a variety of validity conditions. Ad- olescents were eliminated from the research sample if any of the following conditions were met. 1. Gender was not indicated. : 2. The MAPI test report (based on the orig- inal 150 MAPI items) was invalid (using then-current MAPI test-validity condi- tions). 3. Age was less than 13 or greater than 19. 4. Eleven or more item responses were missing from the set of 181 new items. 5. Two of the three original MAPI “reliabil- ity” items OR at least one of the original MAPI “validity” items was endorsed. After the MACI scales were developed, an- other validity condition was added (and used in both phases). Adolescents were eliminated if the following condition was met. ing Scale X.) This left a final size of 579 for Sample A, from which MACI base rates were devel- oped. The two cross-validation samples (Samples B and C) were subjected to an- other validity condition based on final MACI base rate values. Adolescents in Samples B and C were eliminated if the following con- dition was met. 7. Base rate scores for MACI Scales 1 through 8B all had values of 59 or less. The final sizes of Samples B and C were 139 and 194, respectively. The demographic characteristics of the development and cross- validation samples are presented in Table 3. A subset of adolescents from the first phase of the MACT development project was ad- ministered the MACI Research Form on two Separate occasions; the test-retest interval was between three and seven days. Data from the first administration were included in Samples A and B; data from the second administration were used only to estimate the test-retest stability of the MACI scales. Four distinct norm groups were used to con- vert MACI raw scores to base rate scores. ‘These norm groups were subsets of the de- ‘velopment sample (Sample A) and included (@) 166 males 13 to 15 years old, (b) 147 males 16 to 19 years old, (c) 161 females 13 to 15 years old, and (d) 105 females 16 to 19 years old. Demographic information about each of these norm groups is provided in Table 3.2.CHAPTER | 3 Test Development Table 3.1 Demographic Characteristics of the Development and Cross-. Validation Samples Development Sample Cross-Validation Samples A N % N % N % ender Male 313 st ” 3 ra 6 Female 266 6 65 a o 35 Race/Ethnicity Write 460 ” us 8 144 " Black 41 7 u 8 B R Hispanic 35 6 5 4 15 8 Asian 1 o 2 1 o 0 ‘American Indian 15 3 1 1 9 3 Other 16 3 2 o o Not Reported n 2 2 1 3 2 Current Sehoo! Grade High Schoot Tih Grade 40 7 7 5 15 8 8th Grade 16 B 4 0 m 2 St Grade 134 B 2 2B 33 ” 10 Grade na 20 25 8 25 B 1th Grade 87 15 18 B ES 20 12th Grade 37 10 15 n a u College 1Year 3 1 1 1 0 ° 2Years 0 ° o 0 1 1 3Years 0 ° o 0 4 Years o ° o 0 [Not Attending 20 3 4 3 6 a [Not Reported 8 8 B 9 30 15 (continued on next page)‘MACT | Manual Second Edition Table 3.1 continued Development Sample Cross-Validation Samples A W % N % Curent Age 13 years 16 B 9 4 2s B 14 years 19 a » a 322 16 15 years 132 2B 31 2 37 19 16 years 137 m4 3 m 2 a 17 years 93 16 B ” 2 n 18 years 9 3 4 3 6 19 years 3 1 ° ° Current Treatment Seting 8 2 1S u 3 2 n 4 4 3 B 2 Inpatient Mental Hospital 245 a 6 4 38 30 Inpatient General Hospital Unit. 50 9 2 9 - = Sehool Counselor's Office 2 ° 2 i - = Residential Treament Setting 134 B 2 19 37 19 Other 1 9 7 3 18 9 Not Reported 7 1 4 3 13 8 ‘Total Sample Size 579 = 139 = 194 = 30CHAPTER | 3 Test Development Table 3.2 Demographic Characteristics of Norm Groups in the Development Sample (A). Males Females 13-15 Years 16-19 Years. © 13-15 Years 16-19 Years nN % Nn % nN % N % Race/Ethnicity White 131 9 108 B 135 84 86 82 Black 16 10 ao 7 8 5 6 6 Hispanic 10 6 15 10 6 4 4 4 Asian 0 0 1 1 0 0 i) 0 American Indian 3 2 5 3 5 3 2 2 Other gi Sees ne 3003 Not Reported 7 2 2 1 2 1 4 4 Current Treatment Setting Outpatient Clinic/Mental Health 20 12 13 9 2 4 13, 12 Outpatient . Private/Group Practice 8 5 302 see pean Inpatient Mental Hospital, 66. 40 46.31 8553 4846 Inpatient General Hospital Unit 10 6 12 8 17 an ay 10 School Counselor's Office 1 1 1 1 0o 0 0 0 Residential Treatment Setting 42 4933 m4 15 7 16 Other 12 7 23 16 8 5 8 8 Not Reported 5 3 0 0 2 1 0 0 Total Sample Size 165 — week 5 31“-MACI | Manual Second Edition Clinician Judgments ‘The clinicians assessing and/or treating the adolescents who participated in the MACI development project provided information about each of their clients. (All clinicians were paid for their participation.) Most par- ticipating clinicians had only a brief period to become acquainted with the adolescents before evaluating them. Most made their judgments soon after the adolescent started therapy or entered a residential program. The clinicians in the first phase were pre- sented with a list of 10 personality patterns and were asked to indicate which pattern most closely approximated their impres- sion of the client. They were then asked to indicate a second pattern that also fit the individual but not as well as the first. The 10 personality patterns presented to the clini- cians were Introversive, Inhibited, Coopera- tive, Sociable, Confident, Unruly, Forceful, Respectful, Negative, and Sensitive. Note Table 3.3 that Doleful (MACT Scale 2B) aid Border- line Tendency (Scale 9) are not represented in this list of personality pattems and that the names of several of the other personal- ity patterns are not the same as the current Personality Patterns scale names. These Per- sonality Patterns scales were renamed later in the development process. Clinicians were also asked to make simi- Jar judgments using a list of Expressed Concems and Diagnostic Categories (later referred to as Clinical Syndromes). Clini- cians were provided with a brief description of each Personality Pattern and Expressed Concer to help them with their judgments. ‘These descriptions are provided in Table 3.3, which also shows the list of Diagnostic Categories that was presented to each clini- cian, Note that the names of some of the Ex- pressed Concems and Diagnostic Categories (Clinical Syndromes) are not the same as the names of the final MACT scales. Instructions and Information Provided to Clinicians for Making Judgments Concerning Each Adolescent In the grids for Personality Patterns and Expressed Concerns, please mark the characteristic that most Closely approximates your impression of this individual. Please record a second characteristic on each arid that also fits this individual, but perhaps not as well as the first. Personality Patterns Introversive. These individuals are characterized by their lack of affect and their social indifference. They tend to be quiet, passive, and uninvolved. They are often viewed as somewhat dull, quiet, and colorless, unable to make friends, and often indifferent and apathetic. Inhibited. These individuals are usually shy, timid, and nervous in social situations, strongly wishing to be liked and accepted by others, yet often fearing that they will be rejected, They are sensitive and emotionally responsive, yet are also mistrusting, lonely, and isolated. Cooperative. These persons tend to be led by others and to relate in a submissive and dependent man- ner. They may form strong attachments to people who then take a dominant role in decision making. Concerned with losing friends, they cover their true feelings, especially when these may be viewed as objectionable by those they wish to please. 32CHAPTER | 3 Test Development Table 3.3 continued Sociable, -These are people who seek stimulation, excitement, and attention. They may react dramati- cally to situations around them, often becoming very involved in them but typically losing interest quickly. They are colorful and charming socialites, but can also be demanding and controlling. Confident. These individuals tend to feel that they are more competent and gifted than the people around them. They are egocentric and independent-minded people who are often outspoken and self- centered. Many see them also as arrogant, inconsiderate, and exploiting of others. Unruly. These individuals tend to act out in an antisocial manner. They often resist following accept- able standards of behavior, and display a rebellious attitude that may bring them into conflict with pa-~ rental wishes, as well as with school and legal regulations. Forceful. These people are assertive and often domineering and hostile. They tend to see themselves as tough, fearless, and competitive. Warmth, gentleness, and compassion are seen as signs of weak- ness which they avoid by being hard, cold, and aggressive. Respectful. These individuals are described as conscientious, efficient, perfectionistic, and over-con- ‘rolled. They relate-to those in authority in an overly respectful, ingratiating, and dependent manner. ‘They tend to be socially formal and proper and are unlikely to open up and act spontaneously in front of others, Negative. These individuals are characterized by their passive-aggressiveness, sullenness, and general discontent. Their moods and behavior are highly changeable. At times they treat others in an agreeable and friendly manner—on other occasions they are irritable and hostile, expressing the feeling that they ate misunderstood and unappreciated. > Sensitive. These persons are their own worst enemies. They seem to enjoy suffering, tend to demean themselves, act in self-defeating ways, rendering ineffective the efforts of others to assist them, by- passing opportunities for pleasure, and failing repeatedly to achieve despite possessing the abilities to doso. Expressed Concerns Identity Diffusion. Persons with this problem express concern over feeling confused regarding who they are and what they want, Unsure of their identity, they seem unfocused as to their future goals and val- ues in life. They seem directionless and often are unclear as to the kind of person they would like to be. Self-Devaluation. Individuals with this concern may have a sense of who they are, but report experienc- ing a broad range of dissatisfactions with that self-image. They speak openly of feelings of low self- esteem. They find little to admire in themselves, and fear that they will fall far short of what they may aspire to be. Body Disapproval. Youngsters reporting this problem are discontent with the deficits or deviances they perceive in their body maturation or morphology. They are also likely to express dissatisfaction with their level of physical attractiveness and social appeal. Sexual Discomfort. Sexual thoughts and feelings are experienced as confusing or disagreeable to these adolescents. They are troubled by their impulses and often fear the expression of sexuality, being ei- ther preoccupied with or in conflict over the roles it may require. 33MACT | Manual Second Edition Table 3.3 continued Peer Insecurity. Youngsters troubled in this realm report dismay and sadness over being rejected and unadmired by peers. Wanting their approval, but unsuccessful in obtaining it, many are likely to with- draw, feel unhappy, and become even more isolated thereby. Social Insensitivity. Adolescents exhibiting this problem are likely to be cool and indifferent to the wel- fare of others. Willing to override the rights of others to achieve personal ends, they lack empathy and show little interest in building warm or caring personal ties. Family Discord. Youngsters reporting these difficulties find their family both a source and a focus of tension and conflict. Few elements of reciprocal support are noted and there is a general feeling of es- trangement from parents. Depending on personality factors, these difficulties may reflect either paren- tal rejection or, conversely, adolescent rebellion. Academic Inadequacy. These teenagers experience failure in the school setting, Possibly troubled by oor grades, they find little satisfaction either in coursework or extracurricular activities. Somewhat de- moralized about their abilities, these youngsters do not appear motivated to further their education, Childhood Abuse. Adolescents with this history will report shame or disgust over having been subjected to experiences of being abused either verbally, physically, or sexually, ostensibly by parents, siblings, ‘more distant relatives, or family friends. Diagnostic Categories Bulimic Vulnerability » Anorexic Susceptibility Alcohol Predilection Drug Proneness Delinquent Disposition Impulsivity Propensity Anxious Feelings Depressive Affect Suicidal Tendencies Other The first seven Expressed Concerns cor respond to MACI Scales A though G, and the ninth corresponds to Scale H. The eighth Expressed Concem, Academic Inadequacy, was dropped from the final MACI scales. ‘The 10 Diagnostic Categories correspond to the seven MACT Clinical Syndromes (Scales A though GG). When the final Clinical Syndromes scales were developed, the bulimia and anorexia categories were combined to form the Eating Dysfunctions scale, and the alcohol and drug categories were combined to form the Substance-Abuse Proneness scale. (The “Other” diagnostic category of course does not have a MACI scale equivalent.) In the second phase of the MACI develop- ‘ment project (involving Sample C, the cross- validation sample), clinicians made their ratings on a modified rating form. This form included the Doleful and Borderline Ten- dency personality pattems in addition to the 10 that were included in the first phase. TheExpressed Concerns listed were identical to the current Expressed Concerns, and the Di- agnostic Categories were similar to the cur- rent Clinical Syndromes. Scale Development Using data from the MACI development sample, scale development began with an examination of item endorsement frequen cies. Any item with an especially high or Jow endorsement frequency was evaluated to ensure that the frequency was not unex- pected given the content of the item. Items with unexpectedly high or low endorsement frequencies were eliminated from considet- ation. Each item that remained after this first screening was initially assigned to exactly one MACT scale on the basis of its item con- tent. These items were defined as the “proto- type” items for each scale and were assigned a scoring weight of 3 when total raw scale scores were computed, After these preliminary scales were con- structed (Je., scales containing prototype items only), the following statistics were compute: + internal consistency reliability (alpha) * correlation between each item and its total scale score (both the item-included and the item-excluded total scores) * correlations between item responses and the remaining scale scores + adjusted alpha for each item on each scale (i., item-excluded alpha) * correlations between item responses and clinician judgments CHAPTER | 3 Test Development + correlations between scale scores and clinician judgments * correlations among MACI scale scores * correlations between MACT scale scores and scores on the collateral in- struments + correlations between MACI scale scores and MAPI scale scores ‘The creation of the final MACT scales was an iterative process in which all ofthe sta- tistics listed above were recomputed and re- evaluated as items were added to or removed from each scale at each iteration. Nonproto- type items were assigned a scoring weight of 2 or I depending on their consonance with the underlying theory and the strength of their item statistics. MAC test length decreased at each iteration as items were dropped from consideration. Ateach iteration, each remaining item had to appear as a prototype item on exactly one scale. After the first iteration, most items also appeared as nonprototype items on oth- er scales. As a result of this scale develop- ‘ment process, the number of items was re- duced from 331 to the final total of 160. The 160 MACT items can be found in Appendix A. The item composition of the MACT scales and the scoring weight assigned to each item are presented in Appendix B. Base Rate Development All MACI raw scores are’ transformed into base rate scores using one of the base rate (BR) transformation tables in Appendix C. A separate BR transformation table is provided for each of the four norm groups (based on age and gender) described earlier. The baseMACI | Manual Second Edition rate development process followed several distinct steps and is described below. Specifying Target Prevalence Rates Before any BR transformations could be de~’ fined, it was necessary to'specify the popula- tion prevalence rates for the characteristics represented by the MACI Personality Pat- terns, Expressed Concems, and Clinical Syndromes scales. This was done separately for cach of the four norm groups. The target prevalence rate for any scale is the preva- lence of that characteristic in the relevant population. For example, the target preva- ence rate for Scale 2A for 13- to 15-year- old males is the prevalence of the Inhibited personality pattern in that population. This prevalence rate may be different from the target prevalence rate for Scale 2A for 16- to 19-year-old males or for 13- to 15-year-old females. The target prevalence rates were specified using the following steps, In the first step, the clinician judgments that , were provided for each adolescent were used to specify the initial target prevalence rates for each scale within each norm group. That is, within each norm group, the percentage of cases for whom a specific characteristic was judged to be “most prominent” by clini- cians was taken as the initial prevalence rate for that scale and that norm group. This was assumed to be the percentage of adolescents in the corresponding population for whom that characteristic was most prominent. Similarly, the clinician ratings of the second- best-matching characteristic were used to specify the percentage of adolescents in the Population for whom that characteristic was present (though not prominent). In the next step, these empiricaliy derived estimates of population prevalence rates ‘were adjusted to accommodate (a) results from a variety of epidemiological studies 36 | concerning the population prevalence rates of these characteristics and (b) the fact that clinicians in'the first phase of the project were not asked to make judgments concem- ing the Doleful (Scale 2B) personality pat- tem, The adjusted proportions then became the target prevalence rates from which the base rate transformations were developed. Defining BR Anchor Points ‘The base rate scores for each scale are an- chored at BR points 75 and 85, This was done in the following manner, The raw score frequency distribution was determined for each scale (separately for cach nom group). BR scores of 75 and 85 were assigned to the raw scores that corre- sponded to the percentile points represented by the target prevalence rates. For example, suppose the Introversive personality pat- tern was estimated to be the most prominent characteristic for 12% of the population and was estimated to be present (though not prominent) in an additional 7% of the popu- lation. In this case, the raw score on Scale J itroversive) that corresponded to the 88th percentile (ie., 100 - 12) was defined to have a BR score of 85. Similarly, the raw score on Scale 1 that corresponded to the 81st percentile (100 ~ (12 +7)) was defined to have a BR score of 75. Base rate anchor points were defined in this way for MACI Scales 1 through GG. As a result, the proportion of adolescents in the Population with BR scores greater than 85 for a particular characteristic matches the target proportion of adolescents for whom that characteristic is most prominent. Simi- larly, the proportion of adolescents in the Population with BR scores greater than 75 matches the target proportion of adolescents for whom that characteristic is either present or prominent.Defining BR Scores for Scales 9. Through GG For Scales 9 through GG, the following pro- cess of BR score development was used for each of the four age-by-gender norm groups. 1. Arraw score (i.e., the weighted sum of scored item responses) of zero was as- signed a BR score of zero, and the maxi- ‘mum attained raw score on each scale was assigned a BR score of 115. Then linear interpolation was used to assign initial BR scores to the points between the anchor BR values of 0, 75, 85, and 115. These values were used to construct initial BR tranisformation tables. 2. Using these initial tables as a starting point, initial BR scores were then as- signed to each adolescent in the develop- ment sample, 3. Depending on the values of the initial BR scores on Scales EE (Anxious Feel- ings), FF (Depressive Affect), X (Disclo- sure), Y (Desirability), Z (Debasement), and Scales | through 8B, adjustments were made to the assigned BR scores on selected scales. (These adjustments are discussed in Chapter 5.) 4. After adjusted BR scores were obtained for each adolescent in the norm group, the BR frequency distributions were recalculated. These were evaluated to see how closely they matched the target, prevalence rates for BR scores between 75 and 84 (inclusive) and between 85 and 115 (inclusive). 5. If this evaluation showed that these norm group frequencies were off by more than a few percentage points on any scale, the BR table values between the 75-85-115 anchor BRs were modified for that scale in that group’s transformation table. CHAPTER | 3: Test Development 6. Finally, all of the BR scores for that norm group were reassigned, adjusted, and re-evaluated. This step was repeated until the sample frequencies were as close as possible to the target prevalence rates for that norm group on each scale. Defining BR Scores for Scales 1 Through 8B A slightly different procedure was used to develop base rate transformations for Scales 1 through 8B. For Scales 9 through GG, the intent was to match the target prevalence rates at the anchor points of 75 and 85. How- ever, for Scales 1 through 8B, an additional restriction was placed on the BR transforma- tions. That is, they were also defined so that the proportion of times a specific scale score ‘was observed to be the highest score for an individual matched the target prevalence rate for most prominent characteristic. Similarly, the final BR scores were defined so that the proportion of times a specific scale score ‘was observed to be the second-highest score for an individual matched the target preva- lence rate for the presence of the character- istic. This additional restriction on the nature of the BR transformations meant that linear interpolation could not be routinely applied for BR scores between 0 and 74, between 75 and 85, and between 86 and 115. Defining BR Scores for Scales X, Y, and Z Studies carried out in conjunction with the development of the Disclosure (X), Desir- . ability (¥), and Debasement (Z) scales of the MCMLII™* test (Millon, 1987) indicated that for each of these scales a BR score > 85 should include the highest 10% of the patient population, that BR scores of 75-84 (inclusive) should include the next 15%, that the BR range 35~74 (inclusive) should include the middle 60% of patients, and that BR scores < 35 should include the lowest 37“MACI | Manual Second Eultion Table 3.4 Frequency Table of BR Scores for Scales X,Y, and Z (Total Normative Sample) Scale BR Score Range x y Zz 0-34 13.0% 12.1% 6.4% 35-14 62.7% 66.1% 2.5% 75-84 14.0% 1BA% 11.9% 85-115 10.4% 8.6% 9.2% 15% of the population. BR scores between the anchor points of 35, 75, and 85 were obtained by smoothing the distribution. A similar scheme was employed for the MACI test. Table 3.4 shows the distribution of BR scores for Scales X, ¥, and Z in the total nor- mative sample. Grossman Facet Scales ‘The Grossman facet scales were developed to help maximize the assessment specificity and clinical utility of the MACI Personality Patterns scales. Facet scale development was informed by an earlier factor analytic explo- ration of the Personality Patterns scales by Davis (1994). With that empirical work as a backdrop, the scales were developed using a rational-theoretical approach. Specifically, three facet scales were developed for each of the Personality Patterns, with each facet representing one of the eight structural-fune- tional domains specified by the test’s under- lying theory (see Chapter 2). Scale development was initiated by examin- ing the items from each Personality Pattern scale as a discrete item pool. This approach was designed to maximize the logical mean- ingfulness and clinical relevance of the re- sultant scales with respect to the underlying theory. As mentioned above, each facet scale 38 was designed to measure one of the eight structural-functional domains identified by the theory. ‘The MACT test does not equally represent all eight domains for each personality type. It gives prominence to items that either sur- vived its early sequence of test construction or satisfied what the theory would predict for the presentation of the Personality Pat- tems. For each prototypal personality dis- order, Millon (1990, Millon & Davis, 1996) posits that only two or three of the persono- Jogic domains will be most salient, one to three others will probably be of moderate (supportive) importance, and the remaining domains are likely to be present but possibly more subtle. Which domains present as the most salient differs among the prototypic personality disorders, One prototypal pat- tern may emphasize expressive behavior and cognitive style/content, for example, while another emphasizes self-image and mood/temperament, and so on. The facet scales that were developed for each Person- ality Pattern were determined by which three domains for each personality fit the theory best, combined with rational examination of each personality scale’s item pool. ‘Thus, for each of the 12 Personality Patterns scales, three facets were identified and items were chosen from the scale’s item pool onrational and theoretical grounds to constitute the facet scales. Some of the facet scales were augmented with items (usually one or two at most) that are not scored on their primary personality scale. This was done to increase the raw score range on some shorter facet scales, thereby stabilizing those scales, and to increase the breadth of some of the theoretical constructs. Item responses are simply scored 0 or I rather than weighted because the facets are more unidimensional constructs and do not retain a “prototypal” structure. Appendix D shows the scoring of the facet scales. Separate base rate transfor- CHAPTER | 3. Test Development mations for the facet scales were developed for each of the four MACI nonnative groups (13- to 15-year-old males, 16- to 19-year-old males, 13-to 15-year-old females, and 16- to 19-year-old females). These transformations are presented in Appendix E. Because the facet scales have far fewer items than the pri- mary personality scales have, the BRs range between 0 and 99 rather than 0 and 115. ‘Table 4.3 lists the 36 facet scales along with the number of items and internal consistency reliability estimates. Scale definitions are presented in Table 6.1. 39CHAPTER | 4 Psychometric Characteristics ‘The psychometric characteristics of the MACTtest are described in this chapter. The MACI scales were compared to their MAPI- ‘C(linical) counterparts. (See “History of the MACI Test” in Chapter I for a description of the MAPI-C.) MACI raw scores were cor- related with the base rate scores to which the raw scores are transformed. Traditional esti- ‘mates of reliability (internal consistency and test-retest stability) were computed. Finally, validity was evaluated by comparing MACI scale scores to clinician judgments and to scores on other instruments that assess the same characteristics. Relationship of MACI Scales to MAPI-C Scales Table 4.1 presents the correlations between MACT scales and their corresponding MAPEC scales (using base rate scores for both sets). Inspection of this table reveals that some of the MACT scales represent a significant departure from their MAPI-C counterparts. The correlations reported in this table are rather wide-ranging, extending from a high of .84 (for Scale 5) to a low of .08 (for Scale 1). In part, the lower correla- tions reflect two major changes: modifica- tions to certain underlying constructs (e. Scale 1, Introversive), and normative popu- lation differences between the MAPI-C and MACT tests. MACI norms are based entirely on a clinical sample, almost half of which was composed of acting-out adolescents, resulting in different score distributions on certain scales (e.g., Scale D, Sexual Discom- fort, and Scale F, Social Insensitivity). No comparisons between the MAPI-C and MACT tests can be made for Scales 2B, 6A, 8A, 9, or H, or for any of the Clinical Syn- dromes scales or Modifying Indices because these scales appear only on the MACT test. Effect of Base Rate Trans- formations ‘The effect of transforming MACI raw scores to base rate (BR) scores was evaluated by cor- relating the BR scores with the raw scores on which they were based. These correlations are also presented in Table 4.1. The correlations ‘were computed using data from the two cross- validation samples (B and C) combined. These correlations show that the base rate transformations had little practical effect in terms of the relative ordering of adolescents. For Scales 9 through GG, for example, all correlations were greater than or equal to 0.92; only five of these coefficients were below 0.95. This close relationship between the BR scores and the raw scores is to be expected given the nature of the BR trans- formations (i.., linear interpolation between O and 74, between 75 and 85, and between 86 and 115). 4